Day 1 Housekeeping Introductions Ground rules Factors which

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Day 1

Day 1

�Housekeeping �Introductions �Ground rules

�Housekeeping �Introductions �Ground rules

� Factors which influence and impact on us

� Factors which influence and impact on us

� Hearing � Seeing what THEY hear what THEY see � Feeling what THEY

� Hearing � Seeing what THEY hear what THEY see � Feeling what THEY feel Would you do it differently?

� https: //youtu. be/nok. DDalo_g. M

� https: //youtu. be/nok. DDalo_g. M

�The EOLC Strategy https: //www. gov. uk/government/uploads/system/uploads/attachment_data/file/1 36431/End_of_life_strategy. pdf https: //www. england. nhs. uk/wp-content/uploads/2014/11/actions-eolc.

�The EOLC Strategy https: //www. gov. uk/government/uploads/system/uploads/attachment_data/file/1 36431/End_of_life_strategy. pdf https: //www. england. nhs. uk/wp-content/uploads/2014/11/actions-eolc. pdf �One chance to get it right https: //www. gov. uk/government/uploads/system/uploads/attachment_data/file/3 23188/One_chance_to_get_it_right. pdf �NICE Guidelines https: //www. nice. org. uk/guidance/ng 31 �CQC https: //www. cqc. org. uk/content/new-ambitions-end-life-care

�This is a document that provides guidance or a process to support the patient

�This is a document that provides guidance or a process to support the patient through their end of life journey. �It promotes high quality care for all

Although every individual may have a different idea about what would, for them, constitute

Although every individual may have a different idea about what would, for them, constitute a ‘good death’, for many this would involve: � Being treated as an individual, with dignity and respect; � Being without pain and other symptoms; � Being in familiar surroundings; � and Being in the company of close family and/or friends

Discussions as the end of life approaches Open, honest communication • Identifying triggers for

Discussions as the end of life approaches Open, honest communication • Identifying triggers for discussion Assessment, care planning and review Agreed care plan and regular review of needs and preferences • Assessing needs of carers Coordination of care Strategic coordination • Co-ordination of individual patient care • Rapid response services Delivery of high quality services in different settings High quality care provisions in all settings • Acute hospitals, community, care homes, extra care housing hospices, community hospitals, prisons, secure hospitals and hostels • Ambulance services. Care in the last days of life Identification of the dying phase • Review of needs and preferences for place of death • Support for both patient and carer • Recognition of wishes regarding resuscitation and organ donation. Care after death Recognition that end of life care does not stop at the point of death • Timely verification and certification of death or referral to coroner • Care and support of carer and family, including emotional and practical bereavement support

Actions for End of Life Care: 2014 -16 � Wants to signal a shift

Actions for End of Life Care: 2014 -16 � Wants to signal a shift in focus from ‘place of death’ to the broader ‘experience’ of end of life care. Wherever people are, we want to enable them to live and die well � The number of people dying in their ‘usual place of residence’, i. e. at home or in care homes has risen from under 38% in 2008 to 44. 5% now.

There is no doubt that, in the right hands, the Liverpool Care Pathway supports

There is no doubt that, in the right hands, the Liverpool Care Pathway supports people to experience high quality and compassionate care in the last hours and days of their life Baroness Neuberger (July 2013)

But evidence given to the review has revealed too many serious cases of unacceptable

But evidence given to the review has revealed too many serious cases of unacceptable care where the LCP has been incorrectly implemented. Examples include leaving patients without adequate nutrition, hydration and inappropriately sedated This is not only awful for the patients, but it is deeply distressing to their relatives and carers.

What we have also exposed in this Review is a range of far wider,

What we have also exposed in this Review is a range of far wider, fundamental problems with care for the dying – � a lack of care and compassion, � unavailability of suitably trained staff, � no access to proper palliative care advice outside of 9 -5 Monday to Friday.

� Set up to lead and provide a focus for improving the care for

� Set up to lead and provide a focus for improving the care for this group of people and their families and carers � Followed the publication of the “More Care Less Pathway” report

Care Quality Commission (CQC) NICE (National Institute for Health and Care Excellence) College of

Care Quality Commission (CQC) NICE (National Institute for Health and Care Excellence) College of Health Care Chaplains (CHCC) NHS England Department of Health (DH) NHS Trust Development Authority (NTDA) General Medical Council (GMC) NHS Improving Quality (NHS IQ) General Pharmaceutical Council Nursing and Midwifery Council (NMC) Health and Care Professions Council (HCPC) Public Health England (PHE) Health Education England (HEE) Royal College of GPs Macmillan Cancer Support Royal College of Nursing (RCN) Marie Curie Cancer Care Royal College of Physicians (RCP) National Institute for Health Research (NIHR) Sue Ryder Care

The approach has been developed by the Leadership alliance for the care of Dying

The approach has been developed by the Leadership alliance for the care of Dying People (Lac. DP), a coalition of 21 national organisations concerned to ensure high quality, consistent care for people in the last few days and hours of life. The alliance was established following an independent review of the Liverpool care Pathway for the Dying Patient (Lc. P) July 2013. � The Lc. P was an approach to care developed during the 1990 s, based on the care of the dying within the hospice setting, with the aim of transferring best practice to other settings. � The review panel found evidence of both good and poor care delivered through use of the Lc. P and concluded that in some cases, the Lc. P had come to be regarded as a generic protocol and used as a tick box exercise. � Generic protocols are not the right approach to caring for dying people: � Care should be individualised and reflect the needs and preferences of the dying person and those who are important to them.

This document sets out the approach that should be taken in future in caring

This document sets out the approach that should be taken in future in caring for all dying people in England. � the approach focuses on achieving 5 Priorities for Care. � these make the dying person themselves the focus of care in the last few days and hours of life � and exemplify the high-level outcomes that must be delivered for every dying person.

Recognise One Chance to get it Right 5 Priorities Communicate Involve Support Plan and

Recognise One Chance to get it Right 5 Priorities Communicate Involve Support Plan and DO

This guideline covers the clinical care of adults (18 years and over) who are

This guideline covers the clinical care of adults (18 years and over) who are dying during the last 2 to 3 days of life. � It aims to improve end of life care for people in their last days of life by communicating respectfully and involving them, and the people important to them, in decisions and by maintaining their comfort and dignity. Supporting the 5 Priorities of Care guidance � The guideline covers how to manage common symptoms without causing unacceptable side effects and maintain hydration in the last days of life.

� "Our role is to inspect the quality of end of life care services.

� "Our role is to inspect the quality of end of life care services. We know from our inspections so far there are services that are providing good and outstanding care for people at the end of their lives across hospitals, care homes and hospices. � “However, there are many services that are not delivering this. The priority now must be for services in all areas to adopt the Ambitions and take action to ensure that services are consistently of high quality.

Each person is seen as an individual Each person gets fair access to care

Each person is seen as an individual Each person gets fair access to care Maximising comfort and wellbeing Care is coordinated All staff are prepared to care Each community is prepared to help

� So if we take all these important documents we can clearly recognise that

� So if we take all these important documents we can clearly recognise that as health and social health professionals, to understand the needs of a patient or person, we must first work with them to identify their needs, wishes and preferences as an individual. � One way of doing that is through Advance Care Planning which is the 1 st step in the end of life care pathway…

shows steady progress in care of dying people March 2016 Overall, the results show

shows steady progress in care of dying people March 2016 Overall, the results show that there have been documented improvements in: • Recognition that patients are dying and that they have received holistic assessments of their care • The amount and quality of communication with patients who are able to communicate, and with those identified as important to them • Symptom control for the dying person • Commitment to education, training, reporting and continuous improvement in caring for dying people

� Advance statement � Advance decision � Lasting power of attorney � Funeral arrangements

� Advance statement � Advance decision � Lasting power of attorney � Funeral arrangements

Advanced care planning Advanced statement Advanced decision What they do want What they do

Advanced care planning Advanced statement Advanced decision What they do want What they do not want

 A requesting statement reflecting an individuals preferences and aspirations Formalise what the patients

A requesting statement reflecting an individuals preferences and aspirations Formalise what the patients and their family do wish to happen, allowing them to fill clearer in their own mind Can be useful to clinicians in planning of patients individual care knowing how a person would like to be treated Not legally binding but can/should be used within best interest decisions May also need advanced decision and DNACPR

 Preferred Priorities of Care (PPC) Say it once: my advance care plan “Thinking

Preferred Priorities of Care (PPC) Say it once: my advance care plan “Thinking ahead” My Voice This is me……. . Advanced decision from specific groups such as MND Eliciting preferences form

� An advance decision must relate to a specific treatment and specific circumstances �

� An advance decision must relate to a specific treatment and specific circumstances � Formalises what patients do not wish to happen giving them control � It will only come into affect when capacity lost � Legally � Related binding document to capacity of decision making, mental capacity act

Check. � Lasting power of attorney? � In health and welfare? � Can make

Check. � Lasting power of attorney? � In health and welfare? � Can make decisions in life sustaining treatment? � Is it registered with the office of the Public guardian? � They maybe a deputy under the court of protection if they do not have capacity to appoint a lasting power of attorney. � They may have been appointed an agent by the department of work and pensions for bills etc.

�A lasting power of attorney (LPA) is a legal document that lets you (the

�A lasting power of attorney (LPA) is a legal document that lets you (the ‘donor’) appoint one or more people (known as ‘attorneys’) to help you make decisions or make decisions on your behalf. � This gives you more control over what happens to you if, for example, you have an accident or an illness and can’t make decisions at the time they need to be made (you ‘lack mental capacity’). https: //www. gov. uk/power-of-attorney/overview

� Be careful not to offer CPR as a treatment if not considered successful.

� Be careful not to offer CPR as a treatment if not considered successful. � You � If are only getting preferences does not want CPR = ADRT or support process of u. DNACPR with GP.

UDNACPR Purple Form - Who completes it? - Who owns it? - Where it

UDNACPR Purple Form - Who completes it? - Who owns it? - Where it is stored? - Document in patient’s notes Ensure it is communicated to all that needs to know

1. A CPR is unlikely to be successful � Clinician may fill would not

1. A CPR is unlikely to be successful � Clinician may fill would not benefit at all and could look at Elsie’s prognosis and situation as a 1 A decision 1. B CPR may be successful……… � Elsie has made it clear that she does not want CPR through ACP discussion so could be a 1 b decision. 1. C DNACPR is in accord ……… � Elsie could have a 1 c decision if he completes his ADRT.

� When could you consider starting an advance care planning conversation? � What �

� When could you consider starting an advance care planning conversation? � What � Is an advance statement legally binding? � Do � Is does an ADRT stand for? we have to prove we have capacity? advanced care planning voluntary? � Who can complete a u. DNACPR?

� Surprises you? � Frustrates you? � Worries you? � Comforts/ reassures you? �

� Surprises you? � Frustrates you? � Worries you? � Comforts/ reassures you? � In groups consider… what can we learn from this? Can we change practice or even policy to support diversity or even individuality?

Support Involve

Support Involve

� Thoughts of the paperwork � Considerations…. .

� Thoughts of the paperwork � Considerations…. .