Improving end of life decisions for frail, elderly patients

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Background & Problem

Woodmancote ward cares for General Old Age Medicine (GOAM) and Endocrine patients. A high proportion of elderly and frail patients in this ward and other acute settings have multiple co-morbidities, are increasingly frail, and many are in the last year of their lives. Clinical decision-making in this group is complex and challenging, and may be delayed. The consequences of such a delay might include: poor recognition of end-of-life wishes, a failure to engage in conversation around ceilings of treatment, and protracted interventions in the dying phase with potential resource and life-quality implications.

Aim

To facilitate timely patient engagement and decision-making around ceilings of treatment to enable: appropriate comfort-focused care, end-of-life conversations and honest communication. This may impact of length of stay, reduced readmission, fast-track discharge and avoidance of potentially harmful treatments.

Method

PDSA 1- Working as part of the multi-disciplinary team. Attended the ward twice a day plus weekly MDTs, afternoon huddles, provided education sessions.

PDSA 2 – Simple prompts, placing the Unwell and deteriorating Patient (UP) form into every set of notes, “Friday Forms” to prompt decision making before the weekend.

Using the UP form as framework for MDT discussion. Twice a week I collected data from the UP form around numbers/timing/level of UP decisions.

Results

This data demonstrates that having a GOAM team-member with a skill-set around prognostication and palliative care has a clear and positive impact on clinical decision-making. Other outcomes that directly impact on quality of care in the last year of life will inevitably follow.

Implications

There is an increasing recognition of the needs of frail older people in our health and social care settings, and specialist teams are vital to meet their needs. For Palliative Care to meaningfully impact on care within the last year of life, arguably it should be integrated within all specialties and there may be real benefits in using this model widely across many Hospital teams.