Emergency department team makes end of life care a priority
How one trust created a pathway to enable people to die at home
A standardised pathway for end of life care in emergency departments has won a nursing team the Emergency Nursing category of the 2019 RCNi Nurse Awards
Nurses in Sheffield who developed a comprehensive and compassionate pathway for people at the end of life have won the Emergency Nurse category of the 2019 RCNi Nurse Awards, the profession’s top accolade.
The discharge to die pathway created by nurses at Northern General Hospital includes clear guidance for the multidisciplinary team and drew on the expertise of colleagues in palliative and primary care.
John Gillett says the drive to improve end of life care in the emergency department (ED) began in 2015 when, as a senior charge nurse, he was conducting an appraisal with colleague Jayne Dransfield. ‘We had both lost loved ones but had also experienced good services.
‘If people were at the end of life, our staff were going over and above where they could, but sometimes ED staff were nervous about sending people home in case something went wrong — for example, drugs did not arrive for them, or the community services were not in place.’
‘We felt strongly that good end of life care should be standard and resolved to do something.’
The comfort box – what someone returning home to die might need
- Six green and orange needles
- Two 30mL Luer lock syringes
- Six 2mL syringes
- Two transparent dressings
- One or two syringe driver lines
- One or two yellow butterfly cannulas for syringe driver
- Six continence pads
- Approximately ten pairs of gloves
- Approximately ten aprons
- One urine bottle/bed pan (unless ordered by the front door response team)
- Slide sheet (unless ordered by FDRT)
- Three packs of mouth swabs
- Small sharps box
- Two yellow bags
A collaborative approach and determination across the trust helped move the plan forward as staff in each element of the pathway added their expertise.
‘We weren’t reinventing the wheel,’ says Mr Gillett, ‘but putting together things that were already there.’
It was unfamiliar territory for the ED nurses. ‘There are things around end of life that a palliative care nurse finds easy, but emergency nurses and doctors do not,’ says Mr Gillett. ‘If someone comes in with a broken arm that’s easy for us to fix, but if someone needs oxygen at home we have to find people who can do that.
‘So we tapped into other nurses’ knowledge. I would think about sending patients home with syringe drivers, but the district nurse would think about a urinal and a sharps bin.'
As a result, a 'comfort box' was created for ED teams to give to patients to take home with them. This ensures they and their families have access to essential items without delay.
The pharmacists working in ED had recently rewritten the pre-emptive prescribing for the trust. They highlighted the need for patients to receive medication before they left the department. ‘Nothing too complicated but enough to get them home comfortably,’ says Mr Gillett.
‘There are big mugs for a proper cup of tea. It is the little things that matter to relatives'
‘Also previously ED nurses had experienced errors by doctors unfamiliar with prescribing end of life drugs, which led to delays. The out-of-hours GP volunteered to do this as they do it every day.
‘The ambulance service has been great, and if it is end of life they get people home as quickly as possible.’
Getting staff on board
It was, ultimately, about joining the dots, Mr Gillett says. ‘There were no battles because everyone wanted the same thing – discharge teams, palliative care nurses, pharmacists, GPs, district nurses. It was very refreshing. We ran it by our patient governor and he thought it was great.’
'We tapped into other nurses’ knowledge'
The project was delayed by the trust-wide implementation of an electronic patient record system. ‘We certainly did not want to rush it out and for people to be ill informed. Staff need to be on board and comfortable they can both trust the system and be comfortable having end of life conversations,’ he adds.
Angela Harris, nurse director for acute and emergency medicine at Sheffield Teaching Hospitals NHS Foundation Trust, provided the impetus to get the discharge to die pathway back on the agenda.
‘People say A&E is stressful, but what stresses staff is not being able to give the right care.
‘The pathway had to be as easy to follow in hours as out of hours,’ says Ms Harris. ‘The guidance is on a page of A4 and not overcomplicated, so people read it.’
Discharge to die checklist
- Copy of discharge letter with patient (if written)
- DNACPR (red bordered) sent with patient
- Pre-emptive prescribing medications to go with patient (in hours) or out-of-hours GP contacted to visit and take pre-emptive pack
- Oxygen going in if needed
- Palliative care pack with required kit given
- GP/out-of-hours GP aware by telephone
- District nurse referral done and phoned
- Transport booked (state end of life)
- Syringe driver recharged just before discharge
- Emergency contact number of GP and district nurse given
- PRN medication given before transfer if needed
- Advise relatives that when the patient dies they need to ring the GP
Standardisation is key
Bite-sized training has been delivered through a breakfast club.
‘The ED is not the best place to have end of life conversations but it often happens,’ says Ms Harris.
‘Standardisation is the key thing,’ says Mr Gillett. ‘The front door response team co-located in the ED delivers the pathway and alleviates much of the nervousness about discharging patients home in the final hours or days of their life.
‘They bridge the community and A&E, and have built up the contacts they need. The standard approach during the day makes it easier to replicate and we have had successes overnight.’
Improved relatives' room
What the judges said
Judge Joanne Bosanquet, chief executive of the Foundation of Nursing Studies, says: ‘I was absolutely thrilled with this innovation at Sheffield Teaching Hospitals. It demonstrates a real drive to do the right thing and is totally person-centred.
‘Changing culture in the hospital demanded strong and persistent leadership and Angela Harris certainly mustered the troops across the system to make this work and to sustain the change.
‘Care closer to home and a good death are human rights and Ms Harris is advocating for this brilliantly. Thank you from an alumni of Sheffield School of Nursing!’
Ms Harris successfully applied for a £5,000 grant to refurbish the relatives’ room, and organ donation and bereavement link nurse Jane Luxon set about transforming the facilities for bereaved friends and families.
‘We had a jig around to create two relatives rooms and a viewing room. They are quiet and at the end of a corridor,’ she says. ‘I put a lot of thought into what I put in there. For example there are tub chairs because they feel like they are giving you a hug.
‘And there are big mugs for a proper cup of tea. It is the little things that matter to relatives. There are nice pictures on the wall and counterpanes rather than older blankets to lay over the person who has died. We have little boxes for personal jewellery and handprint sets.
‘And I made sure the money stretched by persuading people to give me furniture at cost or at least discount and I often left with freebies!’
More dignified care
Every day, eight to ten families use the relatives rooms and every week three to five patients are discharged home to die, with contacts for the palliative care in-reach team.
The families of patients who have been discharged home praise the service, but nursing staff also appreciate the guidance to provide the best end of life care. Nurses are glad to be able to meet the patient’s wishes and report it has made care more dignified.
'The ED is not the best place to have end of life conversations but it often happens’
Ms Luxon says: ‘Before we would try to get them home to die because that is what they wanted, but it just didn’t happen and they died in a cubicle in the ED.
‘It makes you so happy that our patients now have what they want and die at home with their family in their chosen environment.’
Organ donations the next step
The next step for the team is to ensure organ donation discussions become central to the end of life pathway.
Ms Harris says: ‘We will also more robustly evaluate how many patients are being sent home through the pathway. However, the effect elsewhere may be more profound as we hear the comment across the organisation: “If the ED can do it on the same day, why does it take days from a ward?”
‘Often with ED the trauma and helicopters are what the public see, but the care and compassion of the team that has developed this service cannot be underestimated.’
A person discharged through the discharge to die pathway
Thomas, a father of two, presented to the Sheffield Teaching Hospitals NHS Foundation Trust's emergency department (ED) with a one-day history of dizziness, vertigo, photophobia and nausea, and on examination was found to have nystagmus.
A CT head scan showed a further right frontal haemorrhagic infarct. Initially the plan was to transfer him to the stroke unit but Thomas declined this transfer and wanted to return home to die.
He had been diagnosed with cancer of unknown primary and was in the terminal stage of his illness.
Thomas was referred to the ED's front door response team for a fast track discharge using the palliative care pathway and an assessment was completed identifying his care and equipment needs.
A referral was made to intensive home nursing for end of life care and equipment such as a hospital bed ordered. A referral was also made to the district nursing service for palliative care and management of the driver, which was set up in the ED.
The ED end of life team liaised with Thomas’s GP verbally and electronically, and obtained the pre-emptive drugs required.
Thomas was given a comfort box and a priority ambulance was organised. He was discharged home and died 48 hours later at home with his family.