Standard 6: Quality care during the last days of life - Example GP Practice Team EOLC group exercise

Record: Those attended, apologies, and date of meeting

The aim:

  • For the practice to consider how the Five Priorities of Care during the last days of life are regularly assessed, reviewed and met to improve care for all people with expected deaths (i.e. known to have an advanced serious illness or frailty and on the practice 'Supportive Care Register').

Principles

Prompts for Practice2

  • RECOGNISE
    The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly. Always consider reversible causes, e.g. infection, dehydration, hypercalcaemia, etc.

  • COMMUNICATE
    Sensitive communication takes place between staff and the dying person, and those identified as important to them.

  • INVOLVE
    The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.

  • SUPPORT
    The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.

  • PLAN & DO
    An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion.

    It is helpful to note NICE guidance care of dying adults in the last days of life (NG31).3  Or read the RCGP/Marie Curie Top Tips based on NICE Guidance NG314

Discussion

In 2013, the Independent Review of the Liverpool Care Pathway panel published its report. In response, 21 national organisations came together to form the Leadership Alliance for the Care of Dying People. The purpose of the Alliance was to take collective action to secure improvements in the consistency of care given in England. The Five Priorities of Care for the Dying Person set out the approach to caring for dying people across all settings, to ensure high quality, consistent care for people in the last few days and hours of life.1 There are associated duties and responsibilities of health and care professionals.2

The priorities for care reinforce that the focus for care in the last few days and hours of life must be the person who is dying. These priorities are all equally important to achieving good care in the last days and hours of life. Each one supports the primary principle that individual care must be provided according to the needs and wishes of the dying person. To this end the priorities are set out in sequential order. The priorities are that, when it is thought that a person may die within the next few days or hours of life:

RCGP Daffodil Standards priority list

This document deals specifically with the priorities for care when a person is imminently dying, i.e. death is expected within a few hours or very few days. However, it should be noted that, for people living with life-limiting illness, the general principles of good palliative and end of life care (reflected in the Duties and Responsibilities) apply from a much earlier point. Advance care planning, symptom control, rehabilitation to maximise social participation, and emotional and spiritual support are all important in helping any individual to live well until they die.2

The Duties and Responsibilities relate to care and treatment decisions made when a person has capacity to decide and when someone lacks capacity to make a particular decision. Anyone who works with or cares for an adult who lacks capacity to make a decision must comply with the Mental Capacity Act 2005 when making decisions or acting for that person.2

Task

  • Consider a sample, for example, the last 5-10 patients, who have had an expected death (that is, known to have ASI, EOLC or Frailty needs)
  1. Was the person identified on the practice 'Supportive Care Register'?
  2. Timeline between diagnosis with Advanced Serious Illness or Frailty; Identification of patient and carer/those important to them; being place on the practice 'Supportive Care Register'; gain PCSP; review at MDT; death; care after death assessment?
  3. Did they have 3 components of PCSP: TEP/ACP/Support Map (see Standard 6)? How did this impact their care?
  4. Which of the Five Priorities of Care were met? How? Are there any opportunities for learning?
  5. Which of the Five Priorities of Care were unmet? Why? Are there any opportunities for learning?
  6. Did you receive patient and/or carer feedback (See Standard 8)? 
  7. How will lessons learned improve future practice? Is there an action plan?
  8. How will lessons learned be shared with you GP networks and wider system?
  • Consider patients on your 'Supportive Care Register'. Reflect on IF and HOW the Five Priorities of Care are met. Include in the team discussion:
  1. Does the practice routinely agree the lead clinician(s), accountable for the overall care?
  2. How does this lead clinician become known to the patient and those important to them?
  3. How does the practice prioritise patients to receive urgent access during routine and out of hours?
  4. What processes are in place to ensure each of the Five Priorities of Care are met for patients in the last days and hours of life, and those important to them? For example, include access to end of life anticipatory medication, syringe pumps; access to specialist palliative care.
  5. Do you receive patient and/or carer feedback? (See example, Standard 8).
  6. How will lessons learned improve future practice? Is there an action plan?
  7. How will lessons learned be shared with you GP networks and wider system?

Informing part of the evidence on Standard 6

  • People with Advanced Serious Illness, Frailty and EOLC needs are timely identified prior to an expected death Five Priorities of Care are met Audit criteria shared and agreed.

Next: Standard 7: Care after death >


References

  1. One Chance to get it Right: Priorities for Care of the Dying Person Published June 2014
  2. Priorities of Care for the Dying Person: Duties and responsibilities of health and care professionals Published June 2014 by Leadership Alliance for the Care of Dying People
  3. NICE guideline [NG31] Care of dying adults in the last days of life Published December 2015
  4. RCGP, Marie Curie and NICE endorsed: Top Tips on NICE guideline; Care of dying adults in the last days of life

 

QI 6: Continuous Improvement

Audit implementation of 5 priorities of care across all deaths and action taken where outcomes achieved do not meet the practice accepted standards. Continuous monitoring of these criteria e.g. pain and symptoms assessed regularly in last days of life.

For example, consider if the practice has a reliable system in place to assess with the patient and those important to them the 5 priorities of care AND document that the 5 priorities of care have been met, where possible. 

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