01 December 2011

An audit of the provision and delivery of care for patients in the last hours or days of life has shown hospitals are reaching high standards of care in a wide variety of areas. The audit included clinical data from over 7,000 patients (from 127 NHS trusts) whose care was supported by the Liverpool Care Pathway for the Dying Patient (LCP), and organisational data regarding provision of care for patients in the last hours or days of life was submitted from 131 NHS trusts in England.

The audit is led by the Marie Curie Palliative Care Institute Liverpool (MCPCIL) in collaboration with the Royal College of Physicians, and supported by Marie Curie Cancer Care and the Department of Health End of Life Care Programme. 

The audit is becoming increasingly vital to NHS trusts, as it has now been listed in the Department of Health 2011-2012 Quality Accounts list of recommended national audits, and is the only national audit listed under ‘End of Life Care’.

The audit measured key performance indicators in eight specific ‘themes’ of care provision and delivery covering both organisational and clinical areas. 

Download the National Care of the Dying Audit - Hospitals executive summary.

While overall, care was of high quality, concerns remain regarding education, training and support for healthcare professionals caring for dying patients, and the limited availability of support services from the specialist palliative care teams. The median figures are:

Patient level key findings – clinical data

Physical comfort of the patient

  • 91% of all patients had written prescriptions available for the five key symptoms (pain, agitation, respiratory tract secretions, nausea and vomiting and breathing difficulties) that may develop in the last hours or days of life so that there is no delay in responding to a symptom if it occurs following an assessment. In some trusts this was achieved in 100% of all patients.
  • Routine, ongoing assessments of the patient show, where assessments were recorded in the last 24 hours, patients were documented as comfortable in over 94% of cases, for those goals relating to symptom control.

Communication

  • Results illustrate that, where data were available, significant conversations are happening with the relatives or carers (eg explanation of the plan of care was achieved in 94% of cases documented), even though it is not always possible to have these conversations with the patient, depending on his or her state of awareness/ability to understand
  • There is wide variation in hospital performance (coded achieved) for goals relating to conversations with the patient regarding awareness of dying, and addressing cultural, spiritual or religious needs at this time. This indicates practice across different hospitals may be very different, which should be a point of discussion when interpreting these results. Some trusts are achieving 100% in these areas.

Multiprofessional decision making

  • For those patients receiving it, clinically assisted (artificial) hydration was more likely to be continued after the multidisciplinary/multiprofessional team discussion than clinically assisted (artificial) nutrition, with around a sixth (16%) of patients still receiving clinically assisted (artificial) hydration after the initial assessment.
  • Documentation of the multidisciplinary/multiprofessional team 3 day review has wide hospital variation. It is encouraging however, that some hospitals are achieving this on 100% of occasions, which could highlight an opportunity for lower performing hospitals to learn from other services.

NCDAH participation

  • Hospital participation has increased by 13% between NCDAH Round 2 and Round 3, with 178 hospitals (from 127 Trusts) submitting a total of 7058 individual patient data sets this time.

Organisational level key findings

Education and training, audit and evaluation

  • We can see an increase between Round 2 and Round 3 in the amount of education and training offered in care of the dying for Medical staff (R2: 74%; R3: 90%). However, the majority of education and training offered is not mandatory.
  • Two-thirds (67%) of all hospital trusts produce routine action plans to improve care of the dying in their organisation, to support continuous quality improvement

Specialist palliative care service provision

  • In almost all trusts (92%) there is an out of hours telephone service in operation.
  • It is recommended that Trusts provide a 7 day face to face service. 20% of participating Trusts had this in place.

NCDAH participation

  • There was a 13% increase in trust participation between NCDAH Round 2 and Round 3, with 131 Hospital Trusts submitting data into the organisational element.

Compliance with document completion

  • Compliance with document completion should be addressed by all hospitals. Compliance in some areas is relatively high, although certain other areas are a specific point for comment, such as communication with the Primary Healthcare Team/GP and appropriate services both prior to and after the death of the patient, goals of care relating to significant conversations with the patient and relatives or carers.

Low compliance may indicate a lack of confidence in certain areas of care delivery, and could point towards further education and training need

The audit report makes a series of recommendations on how to improve services in future, including mandatory training in care of the dying for all healthcare staff caring for dying patients, and a seven-day 9-5 face-to-face palliative care service to support healthcare staff caring for dying patients. The full list of recommendations is attached to this email.

Professor John Ellershaw, director of the Marie Curie Palliative Care Institute Liverpool, said:

‘Hospitals now recognise care of the dying as a core responsibility of their organisation. A good death is central to providing dignified care to patients and their relatives. Care of the dying is everyone’s responsibility’

Dr Kevin Stewart, clinical director, RCP Clinical Effectiveness and Evaluation Unit, said:

How we care for dying patients is an indicator of the patient quality experience across our organisations. Good quality care should be safe, effective, patient-centred, timely, efficient and measurable. The lessons we learn from each audit are fed back in recommendations to hospitals to further improve the care of dying patients, encouraging the sharing of best practice and continually learning and innovating.’

Teresa Tate, medical adviser for Marie Curie Cancer Care said:

Marie Curie Cancer Care believes that everyone should have access to high quality end of life care. This audit shows that training for healthcare staff, and palliative care teams in our hospitals working seven days a week, are essential in achieving this and we must continue to work to make that possible.’

Notes

For further information please contact RCP PR manager Linda Cuthbertson 020 3075 1254, 07748 777919 or linda.cuthbertson@rcplondon.ac.uk.