Enabling Excellent End of Life Care in the ICU

BackgroundPrior to the COVID-19 pandemic, an estimated 10–20% of the UK population died in the intensive care unit (ICU).1 Approximately 70% of these deaths occur after decisions to withhold or withdraw life-sustaining treatments.2 During the pandemic (April 2020-March 2021), one acute London hospital trust reported delivering increased end-of-life care (EOLC) on ICU (with 39.9% of deaths occurring in ICU).An individualised EOLC plan was in use across the trust to support people in their last days of life, however this was used infrequently in ICU.MethodsA staff survey revealed the need for ICU specific EOLC plans, training on difficult discussions and empowerment of nursing staff to collaborate in decision making. These findings align with the literature on EOLC in ICU.3 A multidisciplinary working group devised a template for an ICU-specific individualised EOLC plan. The template was presented at grand round, an educational program on EOLC was delivered to ICU nursing staff, and a series of workshops on difficult conversations commenced with ICU junior doctors.ResultsIn the four months following the rollout of the care plan 29.9% (20/67) of people who died in ICU had an individualised care plan. This represents a 69.8% increase from baseline. Workshops on difficult conversations were evaluated positively by attendees.ConclusionsThe described interventions led to increased awareness of EOLC among ICU staff and an improvement in number of patients having an individualised care plan at EOL.Next stepsongoing review of the EOLC plan using quality improvement methodology;development of a checklist for withdrawal of invasive organ support at the end of life;continuation of the education programme.ReferencesConnolly C, Miskolci O, Phelan D, Buggy D. End-of-life in the ICU: moving from ‘withdrawal of care' to a palliative care, patient-centred approach. British Journal of Anaesthesia, 2016;117(2):143–145. https://doi.org/10.1093/bja/aew109Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow HH, Hovilehto S, Ledoux D, Lippert A, Maia P, Phelan D, Schobersberger W, Wennberg E, Woodcock T, For The Ethicus Study Group. End-of-Life Practices in European Intensive Care Units. JAMA, 2003;290(6):790. https://doi.org/10.1001/jama.290.6.79Griffiths I. What are the challenges for nurses when providing end-of-life care in intensive care units?. British Journal of Nursing, 2019;28(16):1047–1052.

Implementing a novel protocol for withdrawal of CPAP support in COVID-19 patients: a case series.

BACKGROUND: No published protocol to guide the withdrawal of continuous positive airway pressure (CPAP) for patients with COVID-19 exists. CASE SERIES: Description of the introduction of a novel protocol, developed by consensus to guide the withdrawal of CPAP for patients diagnosed as dying with COVID-19 in an acute hospital. OUTCOME: 19 patients died on the high-dependency respiratory unit following treatment with CPAP. 89% died with CPAP withdrawn. The dying trajectory was difficult to predict. Symptoms were managed promptly and effectively with a combination of opioids, benzodiazepines and close medical supervision. No concerns were raised by families regarding the decision making or withdrawal process. DISCUSSION: The use of the protocol ensures a comfortable and dignified death and supports the delivery of individualised care at the end of life. Future research on this topic should focus on qualitative outcomes and consider the applicability of this protocol in other patient groups.

9 Delivering good quality end of life care (EOLC) during a pandemic: the response of the transforming end of life care team (TEOLCT) to COVID-19 in an acute London NHS trust

IntroductionThe COVID-19 pandemic highlighted the need for high quality EOLC, unprecedented in scale and setting. We describe the initiatives led by the UCLH TEOLCT who played a key role in preparing and supporting staff to provide EOLC, as well as providing support for inpatients and their families.MethodsUtilising QI methodology, the TEOLCT rapidly implemented changes in six key areas of practice between 23/03/2020 and 25/08/2020. The multidisciplinary TEOLCT collaborated with Specialist Palliative Care and Clinical Psychology teams to achieve these outcomes.Results(i) Staff education: high demand for teaching, e.g. difficult conversations, EOLC and COVID-19 specific symptom control, for redeployed staff largely inexperienced in EOLC. 1037 clinical staff were trained utilising a combination of socially distanced lectures and video-conferencing/webinars. (ii) Staff support: drop-in sessions were facilitated for >200 staff members. (iii) Guidance and Standard Operating Procedures: for symptom control, non-invasive ventilation withdrawal and communicating with family were collaboratively written and disseminated with appropriate training. (iv) Clinical audit: quality of decision-making and documentation scrutinised by auditing treatment escalation plans and do not attempt cardiopulmonary resuscitation orders, identifying areas of practice improvement and training needs. (v) Clinical support: modifying the SWAN model of care for patients in last days of life, TEOLCT supported care of 107 patients during the pandemic peak (23/03 ‘‘ 15/05/2020), totalling 255 inpatient visits. (vi) Bereavement support: with restricted visiting and changes to after death care, TEOLCT oversaw formal bereavement support for bereaved families of 348/392 patients who died, plus appropriate sign-posting to community services.ConclusionsThe TEOLCT rapidly adapted to an unprecedented clinical challenge, identifying and responding to needs, working towards a common goal and leading a coordinated response to the demand for training and support. The key areas of development will inform future practice to ensure ongoing training and support in future surges.