End of life care is about treatment and care focusing on the needs of the whole person as well as their family and carers. Every year around 6,000 people die in Leicester, Leicestershire and Rutland (LLR). When somebody dies in a place of their choosing, free from pain and with their wishes for how they should be cared for understood and respected by healthcare staff, then it is possible to have a good death.
End of Life programme: System-wide objectives
- ensure that End of Life Care (EoLC) is everyone’s business by increasing the amount of proactive management of EoLC patients so that more people are able to die in their preferred place.
- ensure that health and social care professionals in all settings are able to use Advance Care Plans and keep patient at home where clinically appropriate.
- enable discharge to assess by identifying patients in the last weeks and days of life earlier in hospital and proactive planning for these patients.
- provide co-ordination and case management of care in the community for patients allowing patient needs to be better met.
- avoid inappropriate admissions/re-admissions at the end of life by supporting access to the full EoLC generalist and specialist offer.
- improvements to care planning and adoption of ReSPECT across LLR in January 2020 will help to improve communications and prevent unnecessary admissions into hospital in the last months of life and support community delivery of care.
Primary Care objectives
- working with practices to embed the EoL Daffodil Standards, which are a quality improvement scheme, carried out by practices as a self-assessment to improve the consistency of delivery of EoLC for patients
- earlier identification of patients in primary care on Palliative Care registers. This will help to support patients in the community preventing where possible, an unnecessary admission to hospital in the months and weeks leading to their death.
Education and training
- targeted education and training will support providers to better utilise Advance Care Plans and manage patients at home where clinically appropriate, therefore avoiding unnecessary admissions to hospital by ensuring that the right patient care is provided and that communication across all parties is clear and effective.
Service re-design and development
- support the integration/alignment of specialist Teams across community (LPT) and voluntary sector (LOROS) to ensure that specialist palliative care patients across LLR receive an equitable service.
- delivery of EoLC through generalist services aligned with the delivery of services through the community services re-design programme clarifying the role and responsibilities of District Nursing to deliver generalist EoLC.
- existing end of life resources will be more co-ordinated in their response to patient needs allowing more needs to be met in the community and diverting appropriate EoLC activity away from acute settings of care.
- the Co-ordination hub will prevent ambulance transfers as appropriate community based-care can be rapidly accessed for patients at time of need.