We undertook an audit I the use of our Shared Care (End of Life) Records on Avening Ward and found that the time from decision to use the record and death was as low as 7 hours on average.
In addition, there was rarely a clear plan for out-of-hours staff to follow in the event of deterioration (further medical management versus palliation). Detailed and honest discussion with the patients and their relatives, when the prognosis was uncertain, was only patchily recorded and a diagnosis of dying was under-recognised.
To improve on this, we created a multi-disciplinary group to meet and discuss a new pathway. It started by identifying patients who are deteriorating despite active medical therapy, had limited reversibility, and were at significant risk of dying during this admission or soon after.
Having identified these patients, an MDT meeting would be held in the first 4 hours to discuss appropriate outcomes to explicit features of improvement and deterioration, and include guidance on when palliation is appropriate. In the first 12 hours, conversations should be recorded with the patient and their family to honestly address the possibility of death, explore their concerns and wishes and discuss the medical and palliative plan.
The Pathway is called: Patients with Uncertain Recovery - Planning, Liaising, Engaging (PURPLE).
A preliminary audit has found that we have improved discussions and commencement of palliative approaches 3.5 days prior to death on average. Patients and family are better informed and there is a clearer plan of appropriate treatment for out-of-hours clinicians. It is important to stress that patients can improve and survive to discharge on this pathway also, but have had the opportunity to express their wishes and potentially have their symptoms better managed.
We will continue to audit the pathway and roll it out onto a further ward to improve it further. You can find the pathway here