Endoflife care in an acute hospital setting

1
End-of-life care in an acute hospital setting

• UBHT Palliative Care Team
• J Gibbins, N Alexander, C Kinzel, R McCoubrie,
• K Forbes
• October 2007

2
Aims

• Background
• Audit of end of life care in UBHT
• Limitations of the audit

3
Background

• 50 of the UK population dies in the hospital
  setting
• 1500 deaths in UBHT per year
• Approximately 30 deaths per week
• Crosses all specialties

4
Background

• Variability in the care received by patients at
  the end of life SUPPORT, JAMA 2001
• The Liverpool Care Pathway (LCP)
• hospice model of care into other settings
• LCP not yet implemented within UBHT

5
End of life audit

• Complaint reviewed at Medicine Morbidity
  Mortality meeting
• Would an LCP would have improved patient care and
  prevented complaint ?
• Asked to perform an audit
• End of life pathways part of DHs end of life
  care strategy

6
Aims and objectives

• To establish
• whether a diagnosis of dying had been recorded as
  having been made within UBHT documentation
• level of documentation of the care received by
  patients at the end of life

7
Standards

• The fact that the patient is dying should be
  recorded in the notes
• The aim of treatment should be explained to the
  patient and their relatives
• Non-essential medication discontinued relevant
  oral drugs changed to sc route
• Unnecessary medical and nursing interventions
  discontinued
• Patients should have symptoms documented at least
  once
• Anticipatory sc medication should be prescribed

8
Methods

• Identification all deaths 1st Jan to 31st Mar
  2007
• Notes selected randomly by audit department
• Notes screened to determine if death was possible
  to anticipate
• By medical team
• By audit team (using LCP criteria)
• Bed bound
• Semi-comatose
• Unable to take fluids
• Unable to take tablets

9
Methods

• Audit proforma (LCP as gold standard)
• Case note review
• Medical notes
• Nursing notes
• Drug charts
• Observation and fluid charts

10
Results

• 435 deaths during audit period
• Screened 154 notes
• 100 possible to anticipate
• 54 not possible to anticipate

11
Results - demographics

• Possible to anticipate(n100)
• Gender
• Male 50
• Female 50
• Age
• 19-35 1
• 36-55 10
• 56-70 21
• 71-80 19
• gt80 years 49

12
Results - Demographics

• Possible to anticipate (n100)
• Ethnicity
• White 61
• Black/white 1
• Asian 1
• Not documented 37
• Palliative care team involved
• Yes 27
• No 73

13
Results Timing from admission to death

• No. of days No. of deaths (n100)
• 0 - 6 39
• 7 - 13 18
• 14 - 20 14
• 21 - 27 13
• gt 28 16
• Range 4 hours to 108 days

14
Results Timing from diagnosis of dying to death

• Time No. of deaths(n100)
• lt12 hours 32
• 13 - 24 hours 17
• 25 - 36 hours 17
• 37 - 72 hours 17
• gt 73 hours 17
• Range 4 hours to 402 hours (16.75 days)

15
Main diagnosis/reason for admission

• Anticipated Not anticipated
• Cancer 25 2
• Non cancer 75 52
• Chest infection 18 6
• Stroke/subarachnoid/subdural 15 3
• Infective COPD 7 2
• Sepsis 6 7
• Heart failure 4 1
• Other 25 33

16
Standard 1 - The fact that the patient is dying
should be recorded in the notes

• Of the deaths that were possible to anticipate
• 93 /100 patients
• Documentation in the medical notes
• for best supportive care
• TLC,
• comfort care only
• 7/100 patients
• No clear documentation by the medical team

17
Standard 2 - The aim of treatment should be
explained to the patient and their relatives
Family aware
patient dying
Family aware of underlying diagnosis
comatose
no
yes
Patient aware of
dying
Patient aware of underlying diagnosis
0
20
40
60
80
100
No of patients/family
18
Standard 3a Unnecessary medical interventions
should be discontinued

• Yes No Altered management?
• Blood tests 79 21 yes in 1/21
• Antibiotics 23 44 yes in 1/44
• IV fluids 38 58 yes in 2/58
• Radiology 77 9 yes in 0/9
• BM 44 17 yes in 0/17

19
Examples of medical interventions continued
despite diagnosis of dying

• NG tubes and feeding pts relatives refused
• Multiple attempts at cannulation
• OGD booked, pt had ABG/CXR
• Referrals to orthopaedic team, SALT, physio
• Blood transfusions sliding scales
• Fluid challenges (1/2 hour before death)
• Guedel airways

20
Standard 3b - All patients must have a
resuscitation status (DNAR) documented
21
Standard 4 - All patients must have unnecessary
observations discontinued
22
Standard 4 - All patients must have unnecessary
medications discontinued
23
Standard 5 - All patients must have their
physical symptoms documented (at least once)

• Yes No
• Pain 60 34
• Agitation 55 39
• Dyspnoea 38 55
• Nausea 27 66
• Vomiting 14 79
• Resp tract secretions 40 53

24
Standard 6 - All patients must have anticipatory
medications prescribed

• Prescribed Not prescribed
• Pain 71 19
• Agitation 52 38
• Dyspnoea 12 78
• Nausea vomiting 51 39
• Chest secretions 45 45

25
Standard 6 - All patients must have anticipatory
medications prescribed

• Pain Yes No
• Prescribed? 71 19
• Dose appropriate? 55 35
• Route appropriate? 45 45
• Correct frequency? 38 52
• Indication recorded? 25 68

26
Limitations of methods

• Generally poor documentation
• Anticipation of dying was retrospective
• Symptom assessment included time from diagnosing
  dying to death
• Four hour cut off
• Important areas of patient care have not been
  included
• ITU deaths
• Unmeasurable areas

27
Causes for concern within audit data

• Patients expressing a wish to die, but
  interventions continued
• Diagnosis of dying made by on call team/junior
  staff
• Resuscitation decisions confusing
• Family being asked to decide about DNAR
• Dying but still for resuscitation
• Documentation in several different areas
• Inappropriate symptom control measures
• Morphine for agitation and distress
• Suctioning for chest secretions
• Patients allowed to pleasure feed but treated for
  chest infection

28
Conclusions

• Large proportion of deaths are predictable in 4
  hours or greater (100/154)
• Average length of time from recognition of dying
  to death is short
• in 50 less than 24 hours
• in 87 less than 72 hours

29
Areas of good practice

• Patients are diagnosed as dying and this is
  documented (93), but late
• DNAR documentation (87)
• Talking to relatives about underlying diagnosis
  and diagnosis of dying (90 84)

30
Areas for improvement

• Diagnosing dying
• Talking to the patients
• Underlying diagnosis and diagnosis of dying
• Symptom assessment ongoing symptom control
• Anticipatory prescribing
• Pain, dyspnoea, agitation, NV, chest secretions
• Review and discontinuation of unnecessary
• Medications, observations, investigations

31
Questions