Practice question

Surprise questions that can improve end of life care

Healthcare professionals can help meet the needs of older people approaching the end of life by asking the right questions

Healthcare professionals can help meet the needs of older people approaching the end of life by asking the right questions

Picture shows a care home supervisor talking to a resident. Healthcare professionals can help meet the needs of older people approaching the end of life by asking the right questions.
Planning for end of life care is vital. Picture: Stephen Shepherd

The NHS Long Term Plan (NHS England 2019) pledges to introduce personalised and proactive care planning for people identified as being in their final year of life. Improving communication with older people is vital to this.

The use of anticipatory care plans (Fairbairn and Traue 2017), treatment escalation plans  (National Institute for Health Research (NIHR) 2015), advance care planning (Hayes et al 2011) and the Recommended Summary Plan for Emergency Care and Treatment process (Resuscitation Council (UK) 2018) can all help to improve communication with older people about end of life care needs and wishes.

However, an NIHR (2015) review found that hospital staff had difficulty recognising that people were approaching the end of life, discussing prognosis and involving them in decisions about their care in the last few days or weeks of life. More older people die in hospital than anywhere else, but in successive national surveys end of life care in hospital is rated consistently lower than care in hospices, at home or in care homes (Office for National Statistics 2016).

Training healthcare professionals to have the confidence to support people at the end of life is challenging, because of lack of access and staff shortages (Pearce 2019). Bespoke training is also costly and time-consuming, leading to further workforce pressures.

Supporting older people to be heard in a timely fashion is vital

Healthcare professionals in primary and community care can be helped to identify a patient in their last year of life and consider a multidisciplinary team (MDT) approach to care by asking themselves,  ‘Would I be surprised if this patient were to die in the next 12 months?’

This approach involves coordinating needs such as advance care planning, comfort measures, assistance with daily activities and family support (Pattison and Romer 2001). However, a pilot study by Weijers et al (2018) asked a second surprise question, ‘Would I be surprised if this patient was still alive after 12 months?’ They found this prompted GPs to plan for anticipatory care. The second surprise question could be used by healthcare professionals working with older people to identify those who might benefit from discussing end of life care.

The first surprise question is still widely used at MDT meetings in primary and palliative care settings to prompt discussions. The second question could be used at weekly MDT meetings in health or social care, especially when an older person has been admitted to an acute hospital or transferred to another care setting after a period of deterioration, or preferably is back at home.

Starting these discussions, talking about death and supporting older people and their significant others to be heard in a timely fashion is vital. All healthcare professionals have a part to play in improving experiences at the end of life.


 Picture of Emma Matthews, a consultant practitioner trainee with the Health Education England (South East) Older People and Frailty Pathway. In this article she says older people approaching the end of life can be helped by asking the right questions.Emma Matthews is a consultant practitioner trainee with the Health Education England (South East) Older People and Frailty Pathway

 

 

References

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