Hospital Dr News

Major improvements needed in end-of-life care

Major improvements need to be made to ensure better care for dying people, and better support for their families, carers, friends, an audit reveals.

The Royal College of Physicians audit on the provision of care for people dying in hospitals has found significant variations in care across hospitals in England.

While every patient has different needs, and some will need more pain relief than others for example, there should be no variation in the quality and provision of services, or training in the care of people dying in hospitals, it says.

Around half of all deaths in England happen in hospitals.

While previous audits had been based on the goals of care within the Liverpool Care Pathway for the Dying Patient (LCP), the new audit sampled the care of dying people in hospital, regardless of whether they were supported by the LCP or other care pathways or frameworks.

Findings on the quality of care include:

– For most patients (87%), healthcare professionals had recognised that they were in the last days of life, but had only told less than half (46%) of patients capable of discussing this.

– Most patients (63-81%) had medication prescribed ‘as required’ for the five key symptoms often experienced near the end of life – pain, agitation, noisy breathing, difficulty in breathing (shortness of breath or dyspnoea), and nausea and vomiting.

– Only 21% of patients capable of having the conversation were asked about their spiritual needs, and only 25% of relatives/carers asked about their own needs.

Hospitals have a responsibility to provide high quality care for patients in their final days of life, and support families, carers and those close to them. The National Care of the Dying Audit for Hospitals was led by the Royal College of Physicians (RCP) in collaboration with the Marie Curie Palliative Care Institute Liverpool (MCPCIL), and funded by Marie Curie Cancer Care and Public Health England.

Findings on the organisation of care included:

– Only 21% of sites had access to face-to-face palliative care services, 7 days per week, despite a longstanding national recommendation that this be provided; most (73%) provided face-to-face services on weekdays only.

– Mandatory training in care of the dying was only required for doctors in 19% of trusts and for nurses in 28%, despite national recommendations that this be provided.

– Only 47% of trusts reported having a formal structured process in place to capture the views of bereaved relatives or friends prior to this audit.

The results provide data for hospitals to identify good and poor practice, and enable them to make changes that will enhance learning and improve care for dying patients. They also provide commissioners with an evidence base to make commissioning decisions.

Based on these findings, the reports recommendations included:

– Hospitals should provide a face-to-face specialist palliative care service from at least 9am to 5pm, seven days per week, to support the care of dying patients and their families, carers or advocates.

– 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.

Dr Kevin Stewart, chair of the Audit Steering Group and clinical director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU), 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.”

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