Features

Dying in hospital and how nurses can improve care

Nearly one third of inpatients are in the last year of their lives and most will die in hospital. So how can nurses in acute settings improve care for these patients?  
End of life care

While surveys consistently show that about two thirds of people want to die at home, more than half of all deaths happen in hospitals. And in their last days, many people are cared for by generalist nursing staff who may be reticent, or even afraid, to talk about what is happening.

Until recently, staff at Barking, Havering and Redbridge University Hospitals NHS Trust werent confident about recognising those who were dying', says nurse and palliative care team leader Heather Wright.

Recognition needed to happen at an earlier stage and there needed to be a culture shift around talking about death.

Now Sunrise B, an acute care of the elderly ward at Queens Hospital in Romford, one of the trusts two hospitals, has received the Gold Standards Framework (GSF) quality hallmark award for the care it provides to patients nearing the

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While surveys consistently show that about two thirds of people want to die at home, more than half of all deaths happen in hospitals. And in their last days, many people are cared for by generalist nursing staff who may be reticent, or even afraid, to talk about what is happening. 


Picture: Alamy

Until recently, staff at Barking, Havering and Redbridge University Hospitals NHS Trust ‘weren’t confident about recognising those who were dying', says nurse and palliative care team leader Heather Wright.   

‘Recognition needed to happen at an earlier stage and there needed to be a culture shift around talking about death.’ 

Now Sunrise B, an acute care of the elderly ward at Queen’s Hospital in Romford, one of the trust’s two hospitals, has received the Gold Standards Framework (GSF) quality hallmark award for the care it provides to patients nearing the end of life. 

GSF began 16 years ago in primary care, with training for those in care homes added in 2006, and acute and community hospitals in 2013, following a pilot programme in 2010. Accreditation for acute hospitals began last year, with more than 40 completing training so far.

The overall aim is to help health and social care professionals become better equipped to take care of patients until they die. 

The framework covers earlier identification of dying, assessing patients’ needs, and planning care for those approaching the end of life. It also ensures patients are offered the chance to have an advance care planning discussion to record their wishes.

‘We’re the missing link, but the biggest too, as most people still die in hospital,’ says Ms Wright. 

Research suggests that around one third of hospital patients are in their last year of life: a study of more than 10,000 patients in Scottish hospitals in 2010 found that 28.8% died within 12 months of admission (goo.gl/KJFWGj).

Queen’s Hospital is no exception. Furthermore, its own figures show that one in ten patients will die during their hospital stay.

Keen to train

The realisation that caring for dying patients is such a large part of what staff do made the trust keen to train generalists who may not have had the chance to develop their skills in this area.

Two wards began a GSF programme, which meant ward managers and a selected member of staff attending six workshops over the following  two years, then passing on knowledge and training to the rest of their teams.

‘If I’m honest, initially it was a bit overwhelming,’ says nurse Diane Drain, one of two end of life care co-ordinators at the trust. ‘We struggled to understand, but then around three or four sessions in – when we began to talk about how we could improve care for our patients – there was a light bulb moment.

‘Suddenly everyone began to think “this can work” and we realised that we were starting to make a difference.’ 

Today, staff are more confident about identifying those who are dying at a much earlier stage, and initiating conversations about patients’ preferences.

Difficult discussion

‘Having discussions several months before someone dies can feel alien,’ Ms Wright admits. ‘But when we are dealing with people who have life-limiting, long-term conditions, who are back and forward to the hospital all the time, we have to ask what they want.’

Ms Wright recalls such a discussion with one patient who had end-stage renal failure. ‘We were able to have a conversation with them and their family months before their death, so we knew they didn’t want to keep coming back to hospital, but wanted to die at home.

‘Thanks to that discussion, we could make sure that the right people were involved in helping them to die at home.

‘Afterwards, we realised that what we had been able to do had made a huge difference to that person and their family. That spurred us on.’

Data from a gold standard ward suggest that the focus on end of life care is cutting re-admissions. From June 2014 until March this year, 103 people were discharged with advance care plans.

Of those, just 18% were readmitted to hospital, with 64 dying at home. ‘And that’s just one ward,’ says Ms Wright. 

The impact of the training is now being felt trust-wide, with plans in place to roll it out across the board. Initiatives include using an orange gerbera flower logo to signal that someone is in the final stages of life.

‘We use it on the patient’s door, so everyone understands,’ says Ms Wright. ‘We also plan to make special bags for those who are collecting a loved one’s belongings. That way everyone in the trust will be aware that the person is bereaved and can be there to support them.’

Refocused minds

Two wards at Airedale General Hospital in West Yorkshire also received the quality hallmark award, presented by the British Geriatrics Society. ‘It’s refocused minds,’ says Tracy Jessop, a senior sister on ward six, a 30-bed medical ward that is half elderly care and half gastroenterology and endocrinology. 

The training builds on Airedale’s dedicated Gold Line phone service, providing those nearing the end of life with instant access to a nurse for advice, help and support. 

The wide range of patients they look after has proved to be the main challenge for Ms Jessop and her team. ‘Being able to find the time to sit and have these discussions can be difficult on a busy ward, but we have to be mindful,’ she says.

Technology helps with system sharing information so everyone can see whether someone else may have begun a conversation, recording any decisions. 

‘The framework has helped less experienced staff in particular to have these kinds of conversations, giving them more confidence,’ says Ms Jessop. ‘The more you do it, the easier it becomes.’

Discussions about dying can be especially hard when it is a young person who is approaching the end of life.

‘When they are younger, it’s usually someone we’ve looked after for some time, so we’ve built up a rapport with them,’ says Ms Jessop. ‘We had one patient who we had known for four or five years and she asked to die on our ward. For me, it’s all about getting the patient the right care at the right time in the right place.’

How to get hospital care right for patients who are nearing the end of life
  • Establish a relationship with patients who are approaching the end of life. ‘Start conversations early and make sure you know what your patients want,’ advises Tracy Jessop.  
  • Don’t be afraid to have a discussion. ‘It’s not easy talking about death and dying,’ Heather Wright acknowledges. ‘A lot of clinicians are frightened and think they’ll be unleashing a lot of emotions that they won’t be able to manage. But patients are frightened too and are often just waiting for someone to ask – they want to talk.’ 
  • Remember that the more you have this kind of conversation, the more confident you become. 
  • It’s not all about talking. ‘You can gain a lot more information just by listening to your patient,’ says Ms Jessop. 
  • Keep going and make it your priority. ‘Of course you’ll have obstacles along the way,’ says Diane Drain. ‘But keep remembering the difference you can make to your patients and their loved ones.’ 
  • Seek buy-in for your plans from all clinicians – not just the nursing staff. ‘It really makes a difference when everyone understands what you’re trying to do,’ says Ms Drain. 
  • Think outside the box. Do you really need to restrict visiting hours or strictly follow the number of visitors a patient can have when they are in their last days of life? ‘It’s a hospital environment, but there really shouldn’t be these kinds of rules for those who are dying,’ says Ms Drain.  
  • Don’t forget that staff may need support too. ‘Having these kinds of conversation is always sad,’ says Ms Jessop. ‘But talk about it as a team and support each other.’  

 

A question to ask yourself: is this patient near the end of life? 

To help clinicians recognise when patients are nearing the end of life, the Gold Standard Framework has created prognostic indicator guidance. Trigger questions include: Would you be surprised if this patient were to die in the next few months, weeks, days? Other general indicators include: decreasing activity, comorbidity, general physical decline, an increasing need for support, unplanned weight loss and increasing unplanned hospital admissions.

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