End of life care must remain multidisciplinary despite financial constraints, argues Rachael Addicott
Between 2012 and 2030 the annual number of deaths in the UK is predicted to rise by 17 per cent. People are dying at an older age and increasingly with a range of complex comorbidities. It is clear that action needs to be taken to ensure we will all have access to high quality care at the end of our lives.
As the NHS enters one of the most financially challenged periods in its history, all the indications point to little or no additional spending on end of life care over the next several years.
Commissioners and providers need to develop innovative and flexible solutions to meet patients’ expectations of care and deliver high quality services within existing resources.
By recognising and taking into consideration existing best practice they can work towards achieving this ambition despite the hard times ahead.
The King’s Fund recently published a report citing examples of best practice using findings from ongoing research in several local health economies across England. Working with the Marie Curie Delivering Choice programmes in Lincolnshire, Leeds and Somerset, we identified a range of mechanisms for improving the quality and efficiency of end of life care delivery and coordination.
One of the overarching themes to emerge was that there is no one size fits all approach: the service must reflect its context, accounting for geography and the existing structure of the local health and social careworkforce.
The important lessons follow the end of life care pathway, as set out in the end of life care strategy, and focus on four broad themes.
Identification of needs
Interviewees across the local health economies spoke of difficulties in identifying the end of life care phase, particularly in non-malignant cases, which can prevent open communication - and subsequently the care planning process.
Training, multidisciplinary co-ordination and access to care records across all relevant professionals and organisations would help to improve the identification and communication of the end of life phase and encourage better coordination from the start.
The research identified a number of key points in time to broach discussions. Staff should be taught what these opportunities are as part of their training: a significant change in a person’s life, such as a move to a care home; a significant decline in health; or once trust has been established with nurse or social worker.
The research found that often a clinician may make a prognosis or identify that a patient is nearing the end of their life, but then not discuss it with the patient. Reasons ranged from uncertainty around the timing of discussions to lack of experience with patients at the end of their lives. Hospital ward staff in particular were identified as needing support to ensure that patients are appropriately discharged to their preferred place of care.
Generalist staff (such as GPs and district nurses) may interact less frequently with patients at the end of their life, compared with specialist palliative care providers. Therefore specialist and generalist staff should work together to help overcome anxieties about discussing death and planning for death. All health and care professionals should receive regular training in end of life care.
Supporting ward staff through dedicated discharge planning in the acute setting can help to promote greater interaction with patients who are nearing the end of their life and encourage more open communication about their care needs.
Participants agreed that good communication and planning of a patient’s needs and wishes is paramount in providing them with high quality care, preventing gaps or duplication, especially in out of hours care.
As mentioned before, dedicated discharge planning was seen as an effective mechanism for helping staff to assess complex cases and to plan for care to be delivered in the place of choice.
However, such arrangements should be developed in a way that ensures all staff involved are aware of their roles and responsibilities and how they fit into the broader coordination of care.
Advanced care planning plays a central part in ensuring patients’ preferences are respected and fulfilled. Advance care planning will only be useful in achieving this aim if the plan is openly and continuously discussed with patients and carers, and shared across the professions and organisations involved in their care. Advance care planning should be seen as an ongoing process, and not as a one-off event.
Whole systems approach
People nearing the end of life need complex care provided across a range of different care settings and by a range of different providers. Therefore, service improvement needs a whole-systems approach - focused on the entire pathway of care from prognosis through to bereavement.
Attention must be given to improving the quality of care along the entire care pathway and across organisational settings, in order to ensure patients receive high quality of care and their wishes are met.
Discharge from the acute sector should be combined with comprehensive 24/7 community care.
It is clear that high quality end of life care cannot be delivered by a single organisational or professional group and it is the combined impact of the range of services that will be able to meet patients’ care needs and preferences.