This project aims to stop the cycle of readmission in crisis by improving end of life care planning starting when a person with dementia is first admitted to a Dorset hospital in an emergency.

Evidence shows that admission to hospital is a trigger for patients and their family to consider their future care needs. However, the evidence also shows that advance care planning cannot be rushed, should not be done at the time of crisis and should be done in stages. (Advance Care Planning; National guidelines, Royal College of Physicians 2009)

This project will recruit a nurse skilled in working with dementia sufferers and their families to be trained in end of life care planning and advance care planning. The nurse will initiate discussion with the patient and their family once the patient is medically stable before discharge from hospital. He/she will visit the patient and their family again following discharge to continue the end of life care planning discussion with them and, to facilitate the completion of a care planning document with them if requested. The nurse will liaise with all the health and social care agencies (GP, community nurses, ambulance service, carers, care home staff, social services) involved in the patient’s care to ensure their advance care plan (patient has capacity to make decisions about healthcare and future healthcare) or end of life care plan (patient has lost capacity –plan made in conjunction with family members) is followed. The nurse will also ensure that carers understand the goals of care and are supported appropriately to ensure the patient receives the best quality of care.

Objectives

• offer patients and their family a chance to discuss end of life care and to complete advance care plans to guide carers and healthcare teams in managing their future care after discharge from hospital.
• a nurse with experience in looking after people with dementia and specially trained in communication and advance care planning will offer advice, guidance and assistance to enable the patient and or their relatives to complete advance care plans.
• if the patient does not have capacity to complete an advance care plan the nurse will talk to the patient and their family to understand their needs and the issues they face. The nurse will help the family to complete an end of life care plan based on their views, any previously expressed wishes of the patient, the patient’s cultural and religious beliefs and, the care and treatment options available.
• documents such as; preferred priorities of care, Advance Decisions to Refuse Treatment, Proactive Elderly Advanced CarE and Do Not Attempt Resuscitation (documents attached) will be used to document the wishes and views of the patient and /or relative if needed and wanted.
• the nurse will liaise with GPs, carers and community healthcare teams to ensure the end of life care plan or advance care plan is disseminated to all relevant individuals and is accessible in an emergency.

Anticipated outcomes

• An opportunity for patients and relatives to discuss the future and any concerns they may have.
• An opportunity for the patient and their relatives to record their priorities for future care.
• Avoidance of inappropriate and distressing emergency admissions to hospital.
• Improved communication between health and social care agencies resulting in seamless care with everyone involved having the information they need to make the right decisions at the right time for the patient.
• Improved end of life care and a dignified death in the place of their choice.

Progress update

• Training of 3 specialist nurses successfully completed February 2013.
• All practitioners also attended advanced communications course.
• Unable to recruit band 5 to backfill nursing roles and sickness delayed start of project until May 2013.
• End of life care planning with PEACE going well- 23 patients recruited – 20 PEACE documents completed, 1 death in hospital [before discharge], 8 deaths in care home, 11 patients still alive.
• BU will commence evaluation interviews [relatives and care homes] in September 2013.
• ACP – 3 patients recruited but 2 did not have capacity to engage in ACP, one patient has had ACP discussion and completed PPoC document with the nurse.
• Older people’s nurse specialists plan to continue to use PEACE for patients with severe dementia admitted to hospital and discharged to care homes. It is planned that this will become part of normal discharge planning to care homes if evaluation is favourable.