Identifying
Patients
‘Earlier identification of people
nearing the end of their life and inclusion on the register leads
to earlier planning and better coordinated care’(National Primary
Care Snapshopt Audit)
The National GSF Centre and RCGP are
launching the updated fourth edition of the Prognostic Indicator
Guidance,with the aim of helping GPs and other clinicians to
identify patients nearing the end of life earlier and increase the
numbers on the palliative care register.
We know that too few patients are
currently included on the GPs’ QOF (Quality and Outcomes Framework)
palliative care/GSF registers, and that there are a
disproportionally low numbers of non-cancer patients. But we also
know ,that if patients are recognised early and included on the
register they receive better co-ordinated, proactive care that is
more in line with their preferences, as confirmed in the recent
National Primary Care Snapshot Audit (1).
So how can we improve earlier
recognition of these patients? The Prognostic Indicator Guidance
asks three key questions:
- The surprise question. Would you be
surprised if the patient were to die in the next months, weeks or
days? If not, what can you do now to support them?
- Are there general indicators of decline
and increasing need? These include decreased functioning and
activity eg increasingly bed-bound , reduced response to treatment,
, refusal of active treatment, repeated admissions, increasing
impact of co-morbidities, worsening symptoms (such as increased
breathlessness), being admitted to a nursing home among
others
- Are there specific clinical indicators
related to their condition? These could be, for instance,
indicators, for conditions such as heart failure, COPD or
dementia.
If the answer is yes to any
combination of these, then these patients should be included on the
palliative care register and ideally prioritised – ( coded green,
amber or red) – according to need so that support can be more
focused. In addition, extra support should be made available,
advance care planning discussions begun and the process of
proactive planning initiated.
How can we change practice? Better
awareness of those patients nearing the end of life is one aspect
triggering more proactive support. Reflection and audit, can
increase such awareness, using the GSF After Death Analysis (ADA)
tool , Significant Event Analysis or by asking practices the
following key questions:
- What is your register ratio? How many deaths do you have
in your practice population and how many of these are included on
your palliative care/ GSF register in the course of the
year?
- What is your non-cancer/cancer ratio? How many of the
patients on your QOF palliative care register - including care home
residents - have non-cancer conditions?
The National Primary Care Snapshot
Audit in End of life Care 2009-10 (1) suggested the answer to both
these questions was around 25%. This is good news for the minority
that are being picked up early but bad news in that we are still
missing the majority of all patients that die. We know we will
never predict all, but sudden unpredictable deaths are fewer than
most people think (the estimate is about 15%) so if we anticipated
things earlier many more patients could be identified and included
on the register.
The GSF Centre and the RCGP are
involved in a number of other initiatives to encourage best
practice end of life care among GPs and other primary healthcare
professionals. These include an RCGP RCN End of Life Care Patient
Charter that is being distributed to every general practice in
England, a dedicated end of life resource on the RCGP website and a
new palliative care guidance application - the ‘Palli-App’ - which
can be downloaded onto mobile devices and gives instant guidance on
symptom control.
The GSF Centre also launched its Next
Stage GSF Training Programme in Primary Care, Going for
Gold, to help primary care teams put theory into practice
along with the popular ‘GSF-in-a-day’ ‘crash course’ and
BetterTogether workshops for GPs and care homes.. It is
also offering further training for care homes, hospitals and
domiciliary care,some of which will be on the new GSF Virtual
Learning Zone this autumn,
More information
www.rcgp.org.uk/endoflifecare.
www.goldstandardsframework.org.uk
Reference
- http://www.goldstandardsframework.org.uk/GSFInPrimary+Care
Guidance and support in identifying patients nearing the end of
life and introducing advance care planning discussions:
Prognostic Indicator
Guidance (PIG)
This guidance is intended for easier
identification of people nearing the end of their life leading to
earlier planning and better care
PIG guidance (December 2008)