1

Working Together to Transform End of

Life Care in Acute Hospitals

Maggie Morgan-Cooke

Senior Portfolio Manager

Wendy Gray

Senior Programme Manager

3

Working Together to Transform End of Life Care in Acute

Hospitals

Revised and updated for 2015 Reflects Five Year Forward View and

latest evidence from NICE, PHE and

CQC

e-publication

Collaborative venture

8 sections Prepare

Assess & diagnose

Plan

Treat

Evaluate

Sustain

Leading large scale change

Further resources

Making a difference to End of Life Care

The 5 Key

Enablers

AMBER care

bundle

Rapid Discharge

Home

5 Priorities for Care

Advanced Care

Planning

5

Key Enablers

• Advance Care Planning (ACP)

• Identifying and recording a persons wishes and

outcomes of any advance care plan

• Rapid End of Life Transfer

• Developing individual plans of care for anticipatory

management for a predictable clinical event

• The AMBER care bundle

A tool and package of interventions supporting teams

to identify and respond to end of life care needs

when their recovery is uncertain.

6

Key Enablers

• Five Priorities for Care (One chance to get it right, 2014) • The possibility that a person may die within the coming days and hours is

recognised and communicated clearly, decisions about care are made in

accordance with the person’s needs and wishes, and these are reviewed

and revised regularly

• Sensitive communication takes place between staff and the person who is

dying and those important to them

• The dying person, and those identified as important to them, are involved

in decisions about treatment and care

• The people important to the dying person are listened to and their needs

are respected

• Care is tailored to the individual and delivered with compassion – with an

individual care plan in place

7

Key Enablers

• EPaCCs - Electronic Palliative Care Co-ordination System

• Promoting choice by helping deliver 100% national coverage of

EPaCCS and aligning with the National Information Board agenda

• Sharing key information about end of life wishes, care preferences

and key care details for those identified as likely being near the

end of their life

• Rapid discharge Home • Conversations as early as possible, preferably, with the GP and the

patient so that the patient’s wishes and preferences are recorded

as soon as possible

• The process starts with excellent clear communication

• Firstly between patient, family and clinical staff

• Secondly cross boundary communication and documentation

How End of Life Care work is making a positive difference

Making a difference to End of Life Care

How to Guide

The Transform programme

5 key enablers Commissioning Person Centred

Care

9

Key Enablers

• The Transform programme

• Provides hospitals with a

comprehensive service improvement

framework & tools to help you ensure

consistency, reliability, safety and

effectiveness by implementation of 5 key enablers in a

‘How to’ guide

• Supports Trusts to deliver compassionate EoLC of the

highest quality, which is accessible to all who need it

• Over 80 trusts are currently participating

Working Together to Transform End of Life Care in

Acute Hospitals

Ref: Ambitions for Palliative and end of Life care - A national framework for local action

Gaining commitment – to transform end of life care in

acute hospitals – spread and adoption

Shared purpose a sense of clear purpose is essential to

any successful change:

• At every level

• Individuals

• Organisations

• To connect people and build

commitment

• To create the conditions and climate

for leading the change

Never underestimate the work before the

work – organisational readiness

What are you taking away? ….tomorrow I will …..

to accelerate your progress towards improving the quality

and experience of end of life care in your local services : • people have peace of mind that their information is known and

available with their consent to appropriate professionals and that

professionals know and can act on patient preferences about their

death

• that people who recognise they are dying are able to transfer their

care, where appropriate and where that is their choice, to home (or a

care home)

• services in your locality are focussing on compassionate care not just

processes and protocols by enabling an individual to plan for death as

an integral part of personalised care

• a series of conversations are made possible in which a persons

wishes are explored, identified and recorded

• the workforce has the capability to deliver high quality end of life care

across the whole system

The Challenge – making sure that what patients and

carers tell us really influences how we deliver services

“ You can have it in any colour as long as it’s black” – Henry Ford

How do we use what we learn?

14

Opportunities for engagement

• Transform Programme • if your hospital would like to be part of Transform contact

debbie.barnhurst@nhsiq.nhs.uk

• EPaCCS & EPaCCS evaluation • Participate in the evaluation - Contact wendy.gray@nhsiq.nhs.uk

• Find out more about EPaCCS – contact jeri.hawkins@nhsiq.nhs.uk

• Learning and sharing • End of Life Care Facilitators and Champions Network - 850+ members

and still growing!

• Monthly newsletter - Sign up to receive updates from us

• Share and Learn webinars

• Ambitions framework • how you plan to use this framework locally to improve end of life care for

patients and families.

• Get in touch with us at nicola.spencer7@nhs.net

“I can make the last stage of my life as good as possible because everyone

works together confidently, honestly and consistently to help me and the

people who are important to me, including my carer(s).”

maggie.morgan-cooke@nhsiq.nhs.uk

wendy.gray@nhsiq.nhs.uk

@wendyjanegray