Advice for doctors on managing end-of-life care

Poor communication between doctors, and with patients and relatives, is compromising good end-of-life care according to the recently published National Enquiry into Patient Outcome and Death (NCEPOD).

The review – called Caring to the end? – examined the care of patients who died within four days of admission to hospitals in the UK. While 60% of 2,195 patients in the study were judged to have received good medical care, in just over one-third of these cases there was room for improvement and a handful were judged to have been less than satisfactory.

Problems highlighted in the report include poor communication between and within clinical teams. This included failure to consult consultants at an early enough stage, particularly in the evenings and at night time. In some cases where patients were not expected to survive there appeared to be inadequate communication with patients and relatives about appropriate limits to treatment.

The report’s recommendations included:

1. Better systems of handover must be established, and this must include high quality legible medical record keeping.

2. Systems of communication between doctors and other health care professionals must improve. In particular, trainees must seek consultant input at an early stage to assist in the management of emergency patients.

3. The training of nurses and doctors must place emphasis on the basic skills of monitoring vital functions, recognising deterioration, and acting appropriately (which will often be to seek senior input).

The findings echo those of a 2007 report on over 16,000 unresolved NHS complaints which found that care surrounding a death was a factor in 54% of complaints about hospitals, including relatives being given contradictory or confusing information.

Treating and caring for a patient towards the end of their life is invariably challenging for all concerned and emotions may be raw.

The MDU advises doctors that they have a clear, ethical obligation to ensure patients who are dying receive the same respect and standard of care as all other patients, while relatives and partners should be treated with understanding and compassion. If the patient’s prognosis is poor, it is important to ensure their palliative and terminal care needs are identified and that these are clearly noted in the medical records and communicated with colleagues, particularly during handovers.

The following points may helpful in this difficult area:

1. A doctor must recognise and work within the limits of their professional competence. They must be prepared to contact the doctor in charge of the patient’s care if they are not sure how to manage a sudden or unexpected change in their condition.

2. It is important to talk to the patient about their condition or prognosis even where it may be difficult or distressing. Patients may appreciate the opportunity to invite a friend or relative to be present during the discussion.

3. A doctor should establish with the patient what information they want you to share, who with, and in what circumstances, which can help to avoid disclosures that patients might object to. They can also help to avoid misunderstandings with, or causing offence to, anyone the patient would want information to be shared with, such as close relatives or friends.

4. Give patients adequate time to reflect and ask questions, and to change their mind. They should ideally be given the opportunity in advance to decide what arrangements they would like in the final stages of his illness.

5. Information should not be forced on patients if they are clear that they do not want too much detail of their prognosis, but they should be made aware of the impact this might make on future decision-making processes.

6. It may be appropriate to formalise and discuss an advance care plan which would allow patients to indicate what treatment they would like if they lose capacity, or the ability to effectively communicate their wishes. It may also be appropriate to discuss cardio-pulmonary resuscitation if it is likely this may be an option.

7. Competent patients have the right to give, or withhold, consent to treatment and their wishes must be respected.

8. Breaking bad news to relatives is always difficult as their anxiety may mean that not all of what you are saying is taken in. It’s advisable to set out the information in a clear and simple way, explaining any complicated issues in lay terms and avoiding medical terminology. Ensure they have the opportunity to ask questions.

9. It is advisable to record your discussion with patients and relatives in the patient’s medical notes.

Bookmark and Share

Post a Comment

Enter this security code

Submit Comment for Moderation