Standard 6: Quality Care during the last days of life

The General Practice commits to:

To meet this standard the practice commits to:

Self-Assessment

Practice Guidance

6.1 Provide care in the Last Days of Life, that aligns with the Five Priorities for Care

 

 

  1. The possibility that a person may die within the coming days and hours is recognised and communicated clearly, decisions about care are made in accordance with the person's needs and wishes, and these are reviewed and revised regularly.
  2. Sensitive communication takes place between staff and the person who is dying and those important to them. Conversations are appropriately documented.
  3. The dying person, and those identified as important to them, are involved in decisions about treatment and care.
  4. The people important to the dying person are listened to and their needs are respected.
  5. Care is tailored to the individual and delivered with compassion – with an individual care plan in place

A practice policy agreement on caring for patients and those important
to them in the last days of life, to recognise the objectives from the Five Priorities of Care above, to include:

  • Timely recognition of imminently dying person
  • Care is safe, effective, responsive and appropriate
  • Care plans are developed, implemented and reviewed regularly to support people who are imminently dying, their families and carers
  • Timely symptom control assessments using best-practice guidance and tools
  • Evidence that patients, family and carers are provided with information and support in accessible ways
 
  • Active involvement and discussion of the five priorities of care for the dying person. This includes consideration of how to avoid preventable transfers of patients who are imminently dying.
  • Consider how to meet the communication and information needs of patients' with disabilities and sensory loss, in line with NHS England's Accessible Info
  • Consider NICE (NG31)
 

 

 

 

6.1b Implement the five priorities of care
  • Audit to evidence implementation.
  • Invite and review feedback from patients and those important to them.
  • Have an escalation process in place to raise issues and concerns with relevant stakeholder.
 
  • Not all the priorities are easily recorded and hence audited but you need to be practical and audit those that are recorded and encourage future recording.
  • Consider how to best involve patients, families and carers to learn how the practice delivers EOLC
  • Consider how the practice evidences use in practice, in MDTs and PCSPs
  • Consider enablers and barriers to providing high- quality, safe care for people affected by ASI + EOL.

6.2 Provide treatment appropriate to the needs of the patient in the last days of life

 

 

 

 

6.2a Be able to prescribe and have readily available medications to control symptoms and for anticipatory prescribing in the last days of life
 
  • Local guidance within the practice on how to prescribe anticipatory medications.
  • Shared practice agreement on how to access palliative drugs in and out of hours.
 
  • Understand your local prescribing formulary for opioids and other palliative drugs.
  • Understand the process to access palliative drugs in and out of hours.
  • Consider NICE (NG31)
  • The agreement to include palliative drugs covering issues such as:
    • Symptom control: pain, breathlessness, nausea and vomiting, noisy secretions, terminal agitation and delirium
    • Clinically assisted hydration and nutrition
    • Consider reviewing and stopping medications where appropriate
    • Awareness of the legal framework for providing treatment, for example, best interest decisions under the Mental Capacity Act and the need to refer cases to the Court in certain circumstances

 

 

 

 6.2b Be able to access someone to set up and use a syringe driver
  •  Local guidance within the practice on the use of syringe drivers.
  •  Understand best practice prescribing for syringe drivers

6.3 Monitor the quality of care per death provided to include the whole EOL period

 6.3a In practice mortality review for all patients using Mortality review template.
  • At each MDT, discuss, complete and record mortality reviews on all deaths between MDTs, ideally monthly. Mortality review template.
  • SEA for deaths covering the last days of life, written up and discussed with the practice team.
  • Share learning outcomes with team and wider stakeholders, as necessary. e.g. CCG, hospitals, community providers.
 
  • Consider reflection on Expected and Unexpected deaths on any potentially preventable/avoidable harm (for example, poor pain control) and deaths
  • Mortality Review template for deaths
  • For example, evidence of mortality reviews for:
  1. Deaths that were "unexpected" and not on the register but could have been anticipated to see lessons learnt and ensure preventable/avoidable deaths are highlighted
  2. Expected deaths – to ensure high-quality care and support planning took place.
  • Understand the process to refer to Safeguarding Boards in cases where death is linked to abuse or neglect

Next: Standard 7: Care after death >

QI 6: Continuous Improvement

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

For example, consider in 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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