The Registered Nurse at BrendonCare, a registered charity dedicated to improving the quality of life for older people, led a programme to improve awareness, understanding and use of advanced care plans with residents in the home. The programme has resulted in improved experiences for staff, residents and their families.
Where to look
The need for compassion, dignity and respect when caring for people at the end of their life is considered a fundamental value that all health and social care staff should uphold (Culyer, 2014). Recommendations from various public inquiries and reviews including the Francis Report (2013) highlight the need to improve care and emphasise that staff must continue to listen to the people that they care for and to staff who are responsible for that care, so there is continual improvement. In care homes, nurses, care staff and general practitioners provide and support quality care for residents and their families to enable a ‘good death’ and one that reflects and meets their wishes and choices.
This requires key skills which include good communication, spending time with the resident and their family and planning their preferences and choices about dying and recording the outcomes of the discussions. The Royal College of Nursing (RCN, 2018) describe this as a continuous process whereby teams should be consistent in the way they support communication between the resident, their family and allied professionals that support them. In addition, planning a good death helps to maintain quality of life until the end.
To support end of life care, the National Institute for Health and Clinical Excellence (NICE, 2015) has published quality standards for the care of adults approaching End of Life Care, which also include using assessments and other information gathered from the person, those important to them and those providing care to them, to help determine whether the person is nearing death, deteriorating, stable or improving and review the recognition that a person may be dying.
The registered nurse (responsible for compassion in care) identified unwarranted variation within the care home regarding their approach to End of Life Care. Although they were patient centred in care planning, these were often very clinically focused and often only reviewed at the very end stages of life. There was an opportunity to refresh practice at the care home to address this variation in practice.
What to change
Care plans were developed within the home, to capture information around future end of life care wishes, based on reflections and conversations previously captured. Depending on the resident and their family, gathering this information can take a lot of time. Specific information regarding funeral arrangements, spiritual and cultural preferences, resuscitation status and contact information, especially legal representation to make best interest decisions such as Lasting Powers of Attorneys, may be known or at least be easier to identify. Residents may also have other illnesses and health conditions including sensory loss that impact on their wellbeing and the management of their end of life care.
Prior to the change, advanced care plans were mainly discussed and reviewed at the home’s clinical team meeting which involved the resident’s General Practitioner and at shift handover with various discussions taking place with the resident and their family. The registered nurse identified the need for all staff, including agency staff and new staff, to be aware of these needs and preferences, to fully support them in delivering compassionate, consistent care to residents, with flexibility in responding to changing needs. The registered nurse identified the opportunity to introduce a “compassion meeting” into daily practice. This would mean staff could discuss the needs and care of all residents at the end of their life – standardising practice to make improvements across the organisation.
How to change
With the support of the senior team at the care home, the meeting format was agreed and piloted. These meetings are completed in partnership with a resident’s family. This quality improvement process focused on two parallel aspects of care: the way care is organised and the staff interactions with residents and their families. These aspects include liaison with other teams, colleagues and resources.
Implementing the compassion meeting has enabled the nurse to advocate staff awareness of advanced care planning and that this meets residents’ and family needs. A whole team approach is used. Each meeting discusses:
- Symptom management: effective, timely symptom management is an essential aspect of caring for a person at the end of life. They may experience a range of symptoms, including those that are physical, psychological and spiritual and every individual will experience these at different levels of intensity;
- Pain: may result in resistance to care, aggression and agitation. If the resident is unable to communicate, staff are directed to pay more attention to the possibility of pain because if they are in pain, general wellbeing will be hindered. The Abbey pain scale is discussed and its use is encouraged;
- Medication: ensuring staff understand that stopping oral medication does not mean stopping all treatment or that the resident is not being cared for by staff and / or the medical team. This discussion helps staff to understand that by stopping treatment aimed at altering the disease and transitioning to making the person comfortable, the team are providing the care they need to remain dignified and supports quality of life in a resident’s final days;
- Nutrition: at the end of life, people may take only a small amount of food and fluids. Providing food and fluids for as long as someone wants them and can safely take them, is promoted as important;
- Skin integrity: residents at end of life are at high risk of skin damage. The meeting supports to staff to minimise the risk of painful sores; and,
- Environment: considering alongside the family, what is needed for the resident to feel ‘at home’ and comfortable.
At the end of each meeting, the team reflect on the discussions and action plans for what needs to happen next.
Better outcomes – All residents in the home are now offered support to plan for end of life and the enhanced skills of the staff resulting from the meetings now means they can stay in their homes and receive high quality end of life care. This is showing signs of reducing attendance to accident and emergency at end of life. When residents approach end of life stages now, the home staff work effectively and collaboratively to ensure the person’s needs are met.
Better experience – Staff feedback regarding the meetings has been positive. They feel increased confidence in caring for residents at the end of their life. They also report feeling better able to communicate with the families. The meetings have left staff feeling more re-assured about this stage in an individual’s care, with increased support across the team.
Better use of resources – Now, when a person approaches the end of life, the nursing team are better equipped to support their needs. This has reduced medical staff call outs. The meetings support staff awareness of the personalised needs of all individuals and the team have attributed an observed reduction in hospital visits to this shared knowledge and oversight.
Challenges and lessons learnt for implementation
Small changes can have make a big impact.
The compassion meeting helped the team to improve the quality of care for the residents at the end of their life, supported the team to understand better the end of life process and plan for next steps.
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