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Delivering personalised and coordinated end of life care

A ward sister discusses how to provide the best end of life care for patients 

A ward sister discusses how to provide the best end of life care for patients 


Picture: iStock

Nursing someone as they approach the end of their life is a responsibility and a privilege.

To be able to say you have contributed in making a person’s death as good as it could possibly have been is satisfying and can be a valuable reminder of why you entered the profession. It is the ultimate validation of the care we provide at Danetre Community Hospital, part of Northamptonshire Healthcare NHS Foundation Trust, that when we offer patients the opportunity to go home to die, most choose to stay here.

When they are first admitted many people tell us they would they like to die at home. But when they arrive, spend time here and feel safe and well cared for, many change their mind and opt to die here instead. So now we have more patients dying on the ward.

Ten years' difference

Gold Standards Framework

Gold Standards Framework is a UK programme to improve care for patients approaching the end of life. It aims to help health and social care professionals provide coordinated, personalised care for patients and their families and reduce hospital admissions.

It is difficult to imagine that this would have been the case ten years ago. We always provided good quality care, but our communication and coordination of care needed improvement. That’s when we first enrolled on the Gold Standards Framework (GSF) training programme.

Back in 2009, the most appropriate programme for us was the care home one which we adapted to suit our specific needs, focusing on the three important GSF elements of identification, planning and assessment. Thanks to the GSF training, we are now much better at talking to patients and their families and helping them to plan their care. This makes life simpler and easier for everyone.

Some nurses used to say that they did not want to have those difficult conversations as it felt like throwing death and dying in patients’ faces. Now, I walk past and one of my colleagues will be having advance care planning discussions with a patient and their relatives and I think – good on you.

The 29-bed inpatient ward is nurse-led – typically with one nurse and either one or two healthcare assistants working on each of the wards per shift. We provide medical rehabilitation for patients after an acute illness or a deterioration of a long-term condition that needs community hospital inpatient level treatment and support. There are also six beds for palliative patients and these are predominantly for people with a cancer diagnosis.

Advance care planning

The aim is to engage all the patients in advance care planning conversations to help them plan ahead. We always make sure the timing is right, but it is so important for patients, family and staff to establish patients' wishes and what they would like from us at the earliest, appropriate opportunity.

We record every patient’s wishes on an advance care plan and then add it to the trust’s SystmOne computer system. This gives everyone in the trust access to their records, ensuring a much better level of coordination.

Many of our patients will have several admissions, mostly for symptom control, and each time they are admitted or discharged their care plan goes with them, ensuring their care is coordinated and delivered according to their wishes.

We spend longer with the patients and talk to them more and, as a result, there is a more relaxed feeling on the ward. Patients are more comfortable asking us questions about their condition and how it is progressing, and we are more confident about being honest with them and talking them through what to expect. We now have a link with patients and are on their side, advocating for them.

The confidence in the nursing team extends to our relationship with the GPs who provide support to the wards. Each of the wards has a GP surgery supporting them – the palliative team is supported by a surgery based in the same building, as is the out-of-hours team. The other two GP surgeries visit once a day – Monday to Friday. The GPs know I make a lot of the decisions and trust me on that and, as I am doing nurse prescribing now that will make things even easier.

Having advance care plans in place and a nursing team committed to delivering care in line with those plans helps patients fulfil their wishes.

This was illustrated recently when a palliative care patient was admitted with a plan saying they did not want to be admitted to the acute hospital or to receive any more transfusions. They had blood tests and the out-of-hours doctor told the patient that they needed to go to the acute hospital for a transfusion.

The nurse referred the doctor to the patient’s plan and the patient stayed at Danetre, as they had wished. That is exactly as it should be and, as a nurse, it’s so rewarding to have the confidence to deliver that coordinated, personalised care. Putting GSF at the heart of what we do has played a significant part in making this possible.


Patsy Hatfield is a ward sister, Cawthorne Ward, Danetre Community Hospital, Daventry

Danetre Community Hospital in Daventry was a recent recipient of the Gold Standards Framework Quality Hallmark Award for its excellent end of life care provision

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