Concerns over end of life care

Topics covered: Ridouts professional advice

A joint audit into the standards of end of life care in hospitals in England by the Royal College of Physicians and the Marie Curie Palliative Care Institute Liverpool has reported deep concerns.

The audit looked at data from 131 Trusts (90% of those eligible) and found significant variations in care across hospitals in England.  Despite a national recommendation 10 years ago that hospitals provide face-to-face palliative care services seven days a week, only one fifth of hospital were found to provide such a service.

The audit also found that 18% of Trusts had not provided any training in care of the dying and mandatory training was only required for doctors in 19% of trusts and for nurses in 28% of trusts.

For 87% of patients, healthcare professionals had recognised that they were in the last days of life.  However, they had only told 46% of patients capable of discussing this.  Communication with family and friends about the death of a relative or friend occurred in 93% of cases and on average 31 hours before the relative or friend died.

Dr Kevin Stewart, who led the review, said “Although some aspects of care are good in hospitals in England, I am deeply concerned that some hospitals are falling short of the excellent care that should be provided to both dying people and those important to them.  In particular, communication with patients and their families is generally poor.  It is disappointing that hospitals don’t seem to recognise this as an important issue, not just for those experiencing this in their own lives, but for the wider public.  Everyone wants to know that if they are in the same situation, their needs and those of their families, friends and those important to them will be met, with clinically appropriate treatment, sensitivity and compassion.”

The audit makes a number of key recommendations based on the findings.  The recommendations are aimed at driving up the quality of care for dying people across all Trusts.  Key recommendations include:

  • Hospitals should provide a face-to-face specialist palliative care service from at least 9am to 5pm, seven days a week, to support the care of dying patients and their families.
  • Education and training in care of the dying should be mandatory for all staff caring for dying patients.  This should include communication skills training and skills for supporting families and those close to dying patients.
  • All hospitals should undertake local audit of care of the dying, including the assessment of the views of bereaved relatives, at least annually.
  • All Trusts should have a designated Board member and a lay member with specific responsibility for care of the dying.  Trust Boards should formally receive and discuss the report of local audit at least annually.
  • The decision that the patient is in the last hours or days of life should be made by the multidisciplinary team and documented by the senior doctor responsible for the patient’s care.  This should be discussed with the patient where possible and appropriate, and with family, carers or other advocate.
  • Pain control and other symptoms in dying patients should be assessed at least four hourly and medication given promptly if necessary.  Interventions should be discussed with the patient where possible and appropriate, and with family, carers or other advocate.
  • Decisions about the use of clinically assisted (artificial) nutrition and hydration are complex and should be taken by a senior experienced clinician supported by a multidisciplinary team.  They should be discussed with the patient where possible and appropriate, and with family, carers or other advocate.
  • Hospitals should have an adequately staffed and acceptable pastoral care team to ensure that the spiritual needs of dying patients and those close to them are met.

Care and Support Minister Norman Lamb said “All patients should be receiving high quality and compassionate care in their last days of life – there can be no excuse for anything less.  This report shows evidence of very good care but I am seriously concerned about the variations in care, and improvements are needed in the way some clinicians communicate with patients and support families.  I am determined this should improve.”

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