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The End of Life Project

Sydney Local Health District
Project Added:
29 April 2016
Last updated:
16 May 2016

The End of Life Project

Summary

This project implemented a new End of Life Care Plan (EOLCP) at Concord Repatriation General Hospital (CRGH), including end of life care guidelines, staff education and resources for families and carers.

Aim

To improve management of the dying patient in the inpatient setting, with satisfactory outcomes for the recently bereaved.

Benefits

  • Improves documentation of EOLCPs for palliative care patients.
  • Provides safe, high-quality and patient-centred healthcare.
  • Reduces inappropriate and futile interventions for palliative care patients.
  • Improves the experience of families and carers during implementation of an EOLCP.
  • Improves multidisciplinary communication among healthcare professionals.
  • Promotes the principles of communication, shared decision-making and pharmacological care at the end of life.
  • Coordinates the shift from acute to palliative care, reducing the delay of supportive measures at the end of life.

Background

The End of Life Project commenced in an environment of international concern about end of life care, highlighted by a UK investigation by the Parliamentary and Health Service Ombudsman into complaints about end of life care. As a result, rigorous research was undertaken to see if an EOLCP could be implemented safely in an Australian context.

Implementation

  • Stakeholders from executive, clinical and consumer groups were engaged to develop an EOLCP that would be implemented across SLHD. It considered five priorities identified by The Leadership Alliance for the Care of Dying People in the UK, including an inclusive decision-making process between the patient (if possible), family or carer, and the admitting consultant.
  • Family and carer resources were developed with consumer input, including an innovative series of six short videos that helped staff have difficult conversations.
  • EOLCP guidelines and an education package was developed and uploaded to the SLHD intranet for ongoing staff education. Resources included presentations with audio commentary, downloadable patient and family resources in multiple languages, as well as patient and carer fact sheets such as ‘Food and Fluids at the End of Life’.
  • A permanent End of Life Project Officer was recruited to facilitate ongoing education for medical and nursing staff, to ensure safe use of the EOLCP.
  • Each SLHD facility governs the safety and use of the EOLCP through local End of Life Committees, with a SLHD Project Officer providing support as required. The SLHD End of Life Steering Committee provides overall guidance to end of life care throughout the district.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • January 2014 – December 2014

Implementation site

  • Concord Repatriation General Hospital

Partnership

  • Clinical Excellence Commission

Results

  • The following measures were evaluated prior to and following implementation of the project:
    • a medical records audit to assess if documentation of end of life care had improved
    • family and carer satisfaction surveys to assess if end of life conversations were understood by the family and provision of care was seen as appropriate
    • focus groups held prior to project implementation, to engage clinicians with the development of the EOLCP and ascertain the education needs of staff
    • focus groups held following project implementation, to explore the impact of the EOLCP and review changes required.
  • A total of 155 patient files at CRGH were audited during the project, with 61% of patients dying while on an EOLCP. The average time on the EOLCP was four days, which is longer than previous research. This indicates earlier recognition of the dying process and implementation of the EOLCP, confirming that an EOLCP did not hasten death. The EOLCP was stopped in cases where there was meaningful recovery, indicating medical review and appropriate use of the EOLCP.
  • Better patient outcomes were reflected by improved documentation in two key areas: family conversations (including insight into the dying phase) and food and fluids at the end of life. There was no difference in the level of futile medications or treatment, or ordering of medications for end of life symptom management, indicating that the EOLCP is not a template for care.
  • Assessment of spiritual and cultural needs and documentation of skin integrity was improved as a result of the project. The audit found that the EOLCP also prompted nursing staff to provide family and carer resources on end of life care and bereavement.
  • A total of 105 families and carers were asked to participate in the satisfaction survey, with 55% completing the survey. High return rates may have been due to a phone call that was made to eligible families and carers to gain permission for the survey to be sent in the mail. This personalised the process while ensuring the results remained anonymous. The survey showed improved family and carer satisfaction in two categories: ‘end of life issues discussed’ and ‘provision of information’, possibly reflecting the conversations documented in the medical record.
  • After the project, doctors and nurses stated the EOLCP opened channels for multidisciplinary communication, improving coordination and documentation among teams. Doctors suggested that it may help families come to terms with the dying process and reduce the demand for futile treatment by clarifying management goals. Junior medical officers and nurses said that the EOLCP helped with prescription of end of life medications, with some nurses feeling empowered to initiate difficult conversations and provide consistent care and education.
  • The EOLCP project has now been implemented in some wards at Canterbury Hospital, Royal Prince Alfred Hospital and Balmain Hospital.

Awards

  • 2015 NSW Health Awards Nominee – Patients as Partners
  • 2015 SLHD Quality Awards Winner – Patients as Partners

Lessons learnt

  • Staff education is constantly required due to ongoing rotation of junior medical officers and movement of nursing staff.
  • Regular evaluation of medical records and family satisfaction is required to ensure standards are maintained.
  • Initiation and monitoring of the EOLCP requires local champions on each ward.

Further reading

Contact

Tracy Greer
End of Life Project Officer
Sydney Local Health District
Phone: 02 9767 5000
tracy.greer@sswahs.nsw.gov.au

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