Let's Talk: Advance Care Planning. How can we improve the quality of advance care planning both in hospital and community?

BackgroundEnd of life care (EoLC) and advance care planning (ACP) conversations can be challenging for staff and patients. Drawing on published guidance and building on previous local work1–4 this Trustwide project aims to improve the experience of patients, carers and staff in engaging with ACP discussions and to measure progress.Method(s)This project is led by an ACP Nurse Specialist, overseen by the EoLC clinical lead and Deputy Head of Nursing. NHS Quality improvement methodology underpins the work which is supported by a steering group and governance structure.Implementation of our previously developed ‘Let's Talk' resources (supporting information to aid understanding of ACP: videos, leaflet, website5), building stakeholder relationships, staff education, clinical visibility and role modelling were undertaken to increase engagement in ACP. A Gap Analysis Action Plan (GAAP) was developed by benchmarking against recommendations from the Care Quality Commission(2) and used at strategic and governance meetings to engage key stakeholders and agree measureable actions.Data were collated from audits, patient and staff surveys and website viewing clicks.ResultsOver 900 staff have received bespoke training. Changes from pre- to post-implementation include: increased awareness of and staff-reported use of materials (respectively 20%/ 90%;21%/ 75%), increased staff confidence in ACP (30%/ 75%), increased documented use of materials to support cardiopulmonary resuscitation discussions (6%/ 9%). 65% of staff who used materials stated patients/families found them helpful. Website5 clicks increased (520/572) and staff webpage (270/424). Data show increased access to resources and what we hope is a meaningful and sustainable improvement to ACP.Conclusion(s)Our data suggests that our approach to embedding use of our ‘Let's Talk' materials improves staff and patient engagement with ACP. More work is needed to fully develop our Trust framework including a focus on staff and patient education.ReferencesTalking about dying: How to have honest conversations about what lies ahead. Royal College of Physicians. October 2018. Available at: https://www.rcplondon.ac.uk/projects/outputs/talking-about-dying-how-begin-honest-conversations-about-what-lies-ahead [accessed 19/10/2022].Protect, respect, connect – decisions about living and dying well during COVID-19. March 2021. Available at: www.cqc.org.uk/publications/themed-work/protect-respect-connect-decisions-about-living-dying-well-during-covid-19 [accessed 19/10/2022]Universal Principles for Advance Care Planning. NHS England. March 2022. Available at: https://www.england.nhs.uk/publication/universal-principles-for-advance-care-planning/[accessed 19/10/2022].Dying to Talk – Let's Talk: Transforming End of Life Care Conversations. Guy's & St Thomas' NHS Foundation Trust. January 2019. Available at: www.guysandstthomas.nhs.uk/news/dying-talk [accessed 19/10/2022].Let's Talk: Advance Care Planning. Online resource and website – updated September 2022 www.guysandstthomas.nhs.uk/LetsTalk [accessed 19/10/2022].

Development of a learning module to support treatment escalation planning and do-not-attempt cardiopulmonary resuscitation discussions

In response to a need for training in treatment escalation planning (TEP) and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) conversations, and in the context of the Covid-19 pandemic, an interactive on-line training module for healthcare workers was developed. Using four actors, three expert healthcare staff and a multi-media platform, the basic principles of TEP were introduced and explored through two semi-extempore eight-minute clinical scenarios. The videos were punctuated with prompts for leaners to record their reflections, and summaries of relevant policies or legal precedents. After each scenario, learners were invited to make comments on an anonymized public 'notice board'. Following initial evaluation by 285 learners, changes were made to the module in response to comments made in the feedback. Final evaluation by 438 of 602 learners (72.5%) who engaged with the module demonstrated a very positive response (417, 95.2%) to this novel presentation of challenging concepts. Average module completion time was 31 min. Quantitative feedback via an eight-item questionnaire suggested greater confidence around theory than practice: mean score for 'do you understand some of the key considerations and complexities in DNACPR conversations?' was 4.17/5, compared to 3.93/5 for 'to what extent do you feel confident to complete DNACPR conversations appropriately?'. This brief, interactive, on-line learning module proved acceptable to healthcare staff, and led to encouraging levels of confidence in the subject through self-assessment data. It will form a foundation for work-place based staff training in TEP/DNACPR conversations.

Characteristics, Symptom Management, and Outcomes of 101 Patients With COVID-19 Referred for Hospital Palliative Care.

Hospital palliative care is an essential part of the COVID-19 response but data are lacking. We identified symptom burden, management, response to treatment, and outcomes for a case series of 101 inpatients with confirmed COVID-19 referred to hospital palliative care. Patients (64 men, median [interquartile range {IQR}] age 82 [72-89] years, Elixhauser Comorbidity Index 6 [2-10], Australian-modified Karnofsky Performance Status 20 [10-20]) were most frequently referred for end-of-life care or symptom control. Median [IQR] days from hospital admission to referral was 4 [1-12] days. Most prevalent symptoms (n) were breathlessness (67), agitation (43), drowsiness (36), pain (23), and delirium (24). Fifty-eight patients were prescribed a subcutaneous infusion. Frequently used medicines (median [range] dose/24 hours) were opioids (morphine, 10 [5-30] mg; fentanyl, 100 [100-200] mcg; alfentanil, 500 [150-1000] mcg) and midazolam (10 [5-20] mg). Infusions were assessed as at least partially effective for 40/58 patients, while 13 patients died before review. Patients spent a median [IQR] of 2 [1-4] days under the palliative care team, who made 3 [2-5] contacts across patient, family, and clinicians. At March 30, 2020, 75 patients had died; 13 been discharged back to team, home, or hospice; and 13 continued to receive inpatient palliative care. Palliative care is an essential component to the COVID-19 response, and teams must rapidly adapt with new ways of working. Breathlessness and agitation are common but respond well to opioids and benzodiazepines. Availability of subcutaneous infusion pumps is essential. An international minimum data set for palliative care would accelerate finding answers to new questions as the COVID-19 pandemic develops.