Annex 7

GP Cluster Network Development Domain

GUIDANCE NOTE ON THE NATIONAL PRIORITIES FOR QUALITY AND PRODUCTIVITY INDICATORS- END OF LIFE CARE

Introduction

“Dying is a social matter; how well we care for people who are dying reflects on how we care as a society. Where death can be expected we must be prepared to have honest and open conversations about the end of life. It should not be a taboo subject. Preparing and planning for the end of life with the involvement of family, carers and professionals is essential to the delivery of high quality care. We must reach into communities to support people, if they wish, to remain in their home or place of care at the end of life.”

Professor Mark Drakeford (Minister for Health and Social Services)- Together for Health- Delivering End of Life Care (2013)(1).

The primary care team is central to the delivery of high quality end of life care. Primary care teams have longitudinal relationships with patients and their carers, and essential skills in patient centred, holistic care. They are ideally placed to co-ordinate care with other service providers, and manage the worry and stress present at the end of life. Having open and honest conversations, where they are wanted, is essential to giving patients and their carers the time to adjust and make plans for death. This can help ensure effective planned care at difficult times and reduce the risk of crisis management. (2,3)

Many General Practitioners and their teams will have already carried out work to improve end of life care. However, evidence would still suggest that too many people are not dying in their place of choice. Most patients continue to die in hospital even though many could have been supported to die elsewhere (Appendix 1 illustrates this pattern). There is further potential to redesign End of Life care to provide more efficient and effective services which better meet the needs of patients and their carers.

Aim

The Aim of this priority is:

  • To support general practitioners to reviewthe experience of patients at End of Life
  • To support general practitioners to identify and address issues in relation to delivering high quality end of life care.
  • To support general practitioners to share information with members of their network, and, through networks, to support Health Boards/ NHS Wales to progress the End of Life Delivery Plan.
  • To encourage general practitioners to monitor progress (or maintenance of high quality) in the delivery of End of Life Care through further reviews.

Action

The Action required for this priority is:

  • To review the delivery of End of Life Care using Individual Case Review (as developed by the Primary Care Quality and Information Service(4) ( Appendix 2)
  • To summarise case review data, and any arising issues and actions identified,for sharing with the network and the wider health board
  • To establish areview cycle, to monitor progress (or maintenance of high quality), with further submission of reports to the GP cluster and wider health board as appropriate.

For this priority general practitioners will review the care of patients who have died through a retrospective Individual Case Review.

Practices should review deaths that occur between the 1st of January 2014 and the 31st of December 2014, with a particular focus on deaths that might reasonably have been anticipated, to a maximum of a number equivalent to 0.5% of the registered practice list (as of the 1st April 2014).

Practices should use the template developed by the Primary Care Quality and Information Service (Appendix 2).

The resource also contains other activities, including a service review template, which practices may also find useful in delivering service improvement in relation to end of life care.

Practices should identify: -

  • Any appropriate actions to be included in the Practice Development Plan.
  • Themes for discussion in the GP cluster network
  • Issues to be raised with local partners and the Health Board

The practice should contribute outcomes of this work to the GP Cluster Network Annual Report including: summary ofkey themes,actions and outcomes for the local community.

Practices may find the following resources helpful in developing this work:

  • E-Learning for Health site- End of Life Care for All (useful educational resource)
  • Macmillan site for End of Life Care (good source of information for patients relating to many end of life issues)
  • All Wales Palliative Care website- valuable source of templates (Integrated Care Priorities/ Advanced Care Plans/ DNACPR forms etc) and other information in relation to palliative care

References/ Resources

  1. Together for health- Delivering End of Life Care (2013).
  2. Matters of Life and Death RCGP/RCN
  3. Dying Matters The National Council for Primary Care
  4. of life care main document January Final 2013 .docx?OpenElement Primary Care Quality and Information Service - End of Life Care Case review

APPENDIX ONE

Deaths by Place of Occurrence: - ONS 2011

Appendix 2- CASE REVIEW TOOL

Pt ID:

/

END OF LIFE CARE INDIVIDUAL CASE REVIEW AUDIT

Detecting and identifying patients early /

Y

/ N /

Comments

Was the patient on the primary care practice Palliative Care Register six months prior to death
Was the patient on the primary care practice palliative care register at the time of death
Preferred place of death discussed and recorded
Anticipatory care considered and recorded*1
The patient or carer received a completed copy of their care plan
DS1500 form completed

Last days of life

/

Yes

/ No /

Comments

Coordinating care in last days of life - Was the patient entered onto the all Wales Integrated Care priorities for the Last Days of Life (ICP)
Was a home visit made by a GP at the practice, before the patient was entered onto the all Wales Integrated Care priorities for the Last Days of Life (ICP) or alterantive EOLC pathway*2
OOH informed of patient entering onto the all Wales Integrated Care priorities for the Last Days of Life or other End Of Life pathway (See appendix D )
Ongoing management - PRN (Only when required) medications available for the following symptoms in anticipation of; Pain / Nausea & Vomiting / Agitation / Respiratory Tract Secretions
Were there any unplanned/unscheduled admissions during the final days?
All Wales DNACPR Orange form (signed) present in patient notes *3

DNACPR discussed with Next of kin
DNACPR confirmed from Medical notes
Patient assessment content; Physical needs assessed and documented*4
Social needs assessed and documented*4
Mental state assessed and recorded*4
Spiritual needs discussed and recorded ( i.e. signpost family for spiritual guidance if required)*4
After Death /

Yes

/ No /

Comments

The preferred place of death was achieved
The practice offered bereavement support following death of family member
Death was discussed at the following MDT meeting
The family and carers were informed as to what to do / who to contact when death occurred

*1. This criteria aims to ensure that clinicians have considered the need for advanced care planning. Not all patients would wish to discuss or have an ACP.

*2 This criteria aims to ensure “face to face” clinical review before a decision is made to place the patient on ICP- this would normally be within a few days of the decision being made.

*3 The DNACPR form will often be in the patient held record at their house. This criteria is met where either the medical record contains a code that a signed DNA CPR form is present at the house or a scanned copy is present in the records held at the surgery.

*4 These elements form part of the ICP and may have been carried out by other members of the MDT. The ICP will often be in the patient held record at their house. This criteria is met where either the medical record contains reference to this or a scanned copy of ICP is present in the records held at the surgery.

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