End of Life Care in Older people

PEACE

Dr Elena MucciConsultant Physician in the Care of Older People

Department of Medicine for the ElderlyConquest Hospital

Aims and Objectives

Statistics: ageing population

Palliative and End of Life Care for Older

People

End of Life Care policy

Conquest admissions data

PEACE tool

The Ageing UK Demographic

“The absolute number of older adults and their proportion in the population is significantly increasing”- Deaths in older adults: National EOL care intelligence network

People >75years: 1983–2008, Population increased by a third: 2.9million(6%) to 4.0million people(8% total pop).

People 85 years and older: 1985-2010, Population more than doubled:

690,000 to 1.4 million people(2% total pop).

Projections (Office for National Statistics):

By 2033 people aged 75 and over are projected to increase to 7.2 million People aged 90+, 0.4 million (2008) to 1.2 million in 2033.

Source: Mid-year population estimates, UK Office for National Statistics.

Care of the Elderly in the NHS• Francis Inquiry: “many of the cases in which patients and their families

have reported concerns have involved elderly patients”, 2005-2009.• National Confidential Enquiry into Patient Outcome and

Death (NCEPOD): Nearly 40 per cent of people who died within four days of being admitted to hospital received less than good care, 2009

• Care Quality Commission: Elderly suffer poor care in half of NHS hospitals, 2011

• Health Service Ombudsman report: Principles and values of the NHS Constitution are not followed, 2011

• National Audit of Dementia care: the encounter between staff and patients was “mainly task-related and delivered in a largely impersonal manner”, 2012

Palliative and End of Life Care (EoLC) of Older People: Nationally approved tools and suggested practice

2003 DOH: Building on the Best, set out to extend choice to all those approaching the end of their life, not just those with cancer.

2004:National End of Life Care Programme (NEoLCP) , specific objectives of improving the quality of care for all and enabling more patients to live and die in the place of their choice.

2008: End of Life Care Strategy, framework aimed at promoting high quality care across the country for all adults approaching the end of life.

2008: End of Life Care Strategy 'Promoting high quality care for all adults at the end of

life'.

• Identification of people approaching the end of life and initiating discussions about preferences for end of life care;

• Care planning: assessing needs and preferences, agreeing a care plan to reflect these and reviewing these regularly;

• Coordination of care; • Delivery of high quality services in all

locations; • Management of the last days of life; • Care after death; and • Support for carers, both during a

person’s illness and after their death.

EoLC Policy• The White Paper “Equity and Excellence: Liberating the NHS”: “In EoLC, we

will move towards a national choice offer to support people’s preferences about how to have a good death...”

• NHS Outcomes Framework included EoLC in Domain 4 “Ensuring that people have a positive experience of care”, under 4.6 “Improving the experience of care for people at the end of their lives”

• EoLC is one of the 12 work streams within QIPP initiative: seeks to align the quality and productivity agenda. The quality indicator adopted by QIPP- “Proportion of Death in Usual Place of Residence”

• NICE published 16 quality standards for EoLC which are themed around the concept of whole systems approach to holistic care provision in the end of life.

EoLC statistics• Only 40.8% die in their usual place of residence.• 70% say they want to die at home. • 50% have 2 or less unplanned admissions in the last year of

life.• 20% have 5 or more.• Each admission cost on average £3000.• 20% of beds are occupied by dying people who have no

medical reason to be in hospital.• Prevention of one unnecessary hospital admission for only

10% of those who die each year will save £132 million on the tariff and enable 44,000 people to have a better death.

National end of life care programme: NHS based delivery arm of the EOLcare strategy.

Advance Care Planning (ACP) Patients considering and recording their wishes and

preferences for future care at the end of life. Originating

from Preferred Place of Care.

Gold Standards Framework (GSF) Evidence based approach comprising of multiple tools to optimize

the care for patients nearing the end of life. It includes care in the

final year of life for people with any end stage illness. This model

of delivery is for both primary care and care home settings. The

Acute Hospitals Programme (Phase 3) started January

2012.

Liverpool Care Pathway (LCP) Care of the dying in the last hours and days of life. Various

models for application in different settings-phased out, August

2013

Discussions as end of life approaches.

Discussions as end of life approaches.

Care in the last days of life. Care after death

Care in the last days of life. Care after death

Assessment, care planning and review. Co-ordination of care.

Assessment, care planning and review. Co-ordination of care.

Admissions data, Conquest: Sept10-Aug11:

Patients aged 76 and over

Figures not inclusive of MAU admissions

4402: total admissions via A&E For patients aged

76 and over

2530: Single admissions

43% of all admissions, were

readmissions within this cohort.

Admissions data, Conquest: Sept10-Aug11:

Patients aged 76 and over

PEACE projectProactive Elderly Person’s Advisory CarE Planning tool

(PEACE)

• Advance Care Planning• PEACE project• End of Life Care, time to change• Case presentation

Advance Care Planning

A process of discussion between an individual, their care providers, and often those close to them, about their future care. The discussion may lead to:– An advance statement– An advance decision to refuse treatment – The appointment of a personal welfare LPA

Background

• Advance Care Planning National Guidelines (RCP 2009) – Note MCA central to making valid clinical decisions

– No single tool recommended– ACP should be offered during routine clinical practice ideally in

primary care– Discussions should be skilfully led

PEACE

• Developed and used by Geriatricians at KCH&STH

• Recently adopted at Lewisham hospital• End of life care planning tool for NH patients

in primary and secondary care.

Difference between PEACE and LCP

• The LCP was developed by a MDT specialising in hospice care to enable staff in hospitals and in the community to deliver evidence based end of life care. This pathway is only to be used in the last few days of life (the dying phase).

• PEACE is end of life care planning for patients with

worsening chronic conditions who have less than 12 months to live.

Examples of PEACE

• End stage PD-recurrent aspirations.• Advanced dementia-recurrent dehydrations,

not E&D.• Severe disabling stroke-no rehab potential,

poor quality of life.• End stage COPD/CCF-recurrent exacerbations.• Frailty of old age.• Cancer

MM

• 94 year old lady, NH resident for 6/12• 3rd admission with increased confusion in the

last 12 months.• Dehydrated• Bed bound, fully dependant, dementia• Spoke to the son and the NH Matron- EoLCP

done, not for further hospital admissions, unless comfort measures fail.

MB

• 98 year old, lives alone independent• Multiple co-morbidities, daughter helps• EoLC discussed, ACP offered in OP• Patient does not want any interventions, not

even antibiotics, wants DNAR, and wants to die at home-daughter did not have a clue about her wishes!

Aims of PEACE• To improve communication in the transfer of clinical

information between hospital and care home• To provide an individualised document that records the

suggested action plans on progression of illness which have been discussed with patients, relatives and carers by hospital specialists in the care of older people.

• Contribute to advance care planning• Reduce inappropriate hospital readmissions• Improve the quality of care at the end of life

PEACE – Page 1

Suggested Action on Progression of Illness Possible developments identified Three action categories

Intensive Hospital: Consider transfer to hospital for treatment; intubation, ventilation etc. to be considered.

Non–Invasive Hospital: Consider transfer to hospital for treatment. Avoid intubation and ventilation.

Nursing Home: Aim to give treatment, medication and comfort measures within the nursing home with support from GP and other services e.g. Hospice at Home or community specialist palliative care nurses. Aim to avoid admission to hospital unless measures fail. If patient starts to approach last days/weeks of life and in particular finds swallowing increasingly difficult, consider asking GP to prescribe injectable End of Life medications (if not already available). If the patient is in the last few days of life, consider implementing the Liverpool Care Pathway.

Individual advice – specific to development

ExamplePossible developments Action

categoryComments

Aspiration due to delayed swallow

Nursing Home

Follow SALT advice on positioning. On puree diet and sips, position upright. If fatigue noted allow to rest then resume feeding

Dehydration due to reduced oral intake

Nursing Home

As above. Allow plenty of time to help . Avoid future hospital admissions for this.

Recurrent infections Nursing Home

Trial of PO antibiotics by GP if appropriate. Consider referral to palliative team should future deterioration occur.

Mental capacity

PEACE – Page 2

PEACE – Page 3

Summary of discussions with NOK Resuscitation status

Page 4

• Guidance and important contacts.

Key questions for MDMs

Yes No

Is the patient for transfer to a nursing home?

Go to next question PEACE not applicable

Is the nursing home in Hastings and Rother region?

Go to next question PEACE not applicable

Has the patient got an existing PEACE or Advance Care Plan in place?

Review and update existing document

Complete PEACE

PEACE plan CHECKLIST

• Patient is a NURSING HOME* resident• Discussed at MDT meeting-for PEACE• Discussed with patient and/or NOK-agreed for PEACE• PEACE documentation completed• GP informed by a doctor prior to discharge• Nursing home informed by a doctor prior to discharge• PEACE is mentioned at nurse handover prior to discharge• *Some Residential Homes except patients for end of life care.

Please discuss with the home Manager prior to discharge. A member of staff from a Residential Home must review PEACE patients prior to discharge.

PEACE auditDemographics and basic data

• 42 patients (38% males, 62% females) admitted to the Conquest Hospital were later discharged on PEACE documentation between 13/02/2012 and 13/08/2012.

• 120 patients up to now• The average age of patients was: 86.7 years

Mental Capacity

Only 66% of patients had dementia or cognitive impairment recorded at the time of admission, 90.5% of patients were assessed as lacking the capacity to make future care decisions at the time of the PEACE discussion

Reasons for admission

Discharge destination

• During the study period, 81% were discharged to NH and 19% were discharged to RH

• 23 different care homes in Hastings and Rother receiving a patient on the PEACE.

• At the end of the audit time-August 2012- 45% of the patients were still alive with a PEACE plan and 55% had died.

• The average survival from PEACE plan to death was 32.5 days.

PEACE readmissions

PEACE plan: followed

• 98 year old man from a RH• 1st admission:18/05/12-14/06/12 (4 weeks)

with biliary sepsis, became very frail, RH could not meet his needs, placed into a NH with his wife with PEACE plan.

• No hospital admissions in the previous 12 months.

• Patient has capacity to consent to PEACE

PEACE plan: followed

• 2nd admission: 20/09/12-26/09/12 (6 days)-appropriate admission as per patient’s wishes, discharged on updated PEACE plan.

PEACE plan: followed

• RIP on 18/11/12 (53 days later) peacefully at his NH with input from H&H team.

• I interviewed the NH: found the pathway useful, GP felt she had enough support in making EoLC decision and H&H team new about the patient and helped at a short notice.

PEACE plan: not utilised

• 79 year old woman admitted from home• 1st admission: 16/09/12-08/11/12 (55 days)

with confusion/wondering. New diagnosis of dementia. Discharged to NH with PEACE plan.

PEACE plan: not utilised

• 2nd admission: 13/12/12-21/12/12 (9 days) with N&V secondary to constipation leading to dehydration. Inappropriate admission.

• Son is not spoken to prior to arranging the admission.

• RIP on 07/01/13 (17 days later)

Next steps

• Team work and communications are vital• Clinical team identify patients at MDM• Medical team have a key role in completing PEACE

medical information and discussing with patient or representative

• Discharge coordinator and nursing team have key role in communicating with nursing home and supporting process

• Copy of PEACE should be sent with the patient to a nursing home, to the GP and H@H team.

How we care for the dying is an indicator of how we care for all sick and vulnerable people. It is a measure of society as a whole and it is a litmus test for health and social care services.

End of Life Care Strategy 2008.

Any questions or comments?

Dr E Mucci, Consultant Geriatrician, pager 849002 or extension 8181.

Dr Debbie Benson, Consultant in Palliative Care, 01424755255

References www.endoflifecareforadults.nhs.uk/

End of Life Care Strategy www.dh.gov.uk/en/Publicationsandstatistics/

Publications/PublicationsPolicyAndGuidance/DH_086277

http://www.palliative-medicine.org/

http://www.ncpc.org.uk/National Council for Palliative Car

http://www.dyingmatters.org/gp

http://www.endoflifecare-intelligence.org.uk/home.aspx

http://www.dh.gov.uk/publications

Gomes B, Higginson IJ. Where people die (1974-2030). Past trends, future projections and implications for care. Palliative Medicine 2008; 22: 33-41.

Office for National Statistics: www.ons.gov.uk/