Terminal Phase Care Pathway in the Emergency Department

Initiative Type
Model of Care
Status
Deliver
Added
18 April 2019
Last updated
22 May 2019

Summary

Many patients seek care in the Emergency Department (ED) for acute crises related to chronic, life-threatening illnesses. Such visits tend to increase as a patient’s clinical status deteriorates and they approach the end of life. Emergency clinicians have an opportunity to encourage the patient, his or her family, and primary care clinicians to have follow-up discussions about goals of care.

This project provides a multidisciplinary approach to improving the recognition and care of patients nearing end of life in ED. The project has developed a pathway for quality care at end of life, and successfully built the skills and capacity of ED staff to deliver terminal phase care.

The project was adapted from the Time is Precious (TIP) pathway developed by Liverpool Emergency Department in New South Wales.

Key dates
Apr 2018
Implementation sites
Sunshine Coast Hospital and Health Service
Partnerships
Sunshine Coast Hospital and Health Service, Clinical Excellence Queensland

Aim

To implement a standardised pathway for quality care at end of life for patients, their families and carers.

Benefits

  • Early integration of person-centred palliative care can substantially improve patient care for those patients that arrive in the ED at a time when they have reached the limit of available treatment options for health restoration and maintenance.
  • Provision of an approach to care that is focused on shared decision-making between the patient and family, and the treating team so the care provided is in the patient’s best interest, aligns with their wishes and constitutes good medical practice.
  • Improvements in the care and support provided to the patient’s family and loved ones, which may impact later bereavement risk.
  • Increasing the capacity and confidence of ED staff to more adequately care for these patients can have a positive impact on the staff.
  • Implementation of specialised, best practice care that does not require transfer of care to the Specialist Palliative Care team, thus reducing demands on that team.

Background

The Care at the End of Life project team was established to support a coordinated approach to implementing the Strategy across Queensland. Queensland Health's Clinical Excellence Queensland coordinates the implementation of the project, in collaboration with each Hospital and Health Service.

Solutions Implemented

Decision-making and End-of-Life-care in Emergency (DandELinE) Pathway – decision support flowchart outlining the process which includes:

  • Identifying patients who are nearing end of life or imminently dying.
  • Discussing treatment options with the patient’s Substitute Decision Maker (Enduring Power of Attorney (EPOA) / Statutory Health Attorney).
  • Documentation of discussions and outcomes.
  • Implementation of the Care Plan for the Dying Person.
  • Advice regarding medication for pain and symptom management.
  • Disposition planning and transfer of the patient to the preferred transfer or discharge destination.
  • Bereavement support for carers and staff.

DandELinE Resource Trolley – ‘clinical care’ trolley containing appropriate and required end-of-life care equipment and resources including door signs with the purple tree, Handover Bags for deceased patient belongings and the “When Someone Dies” booklet.

Increased capacity for ED staff – education and simulation training in the use of palliative care resources including, Niki pumps, Surefuser, Advance Care Planning documents and The Viewer.

Hand-Crafted Quilts – donated by the local quilting group and already available for patients receiving treatment in the Cancer Care Centre, these quilts are now available in the DandELinE Resource Trolley to help provide a beautiful, less ‘sterile’ environment for the dying patient.

DandELinE Work Place Instruction - designed to support the staff in the SCUH ED when making decisions regarding the validity of providing life-sustaining measures for patients at - or nearing - end of life.

DandELinE Medication for Symptom Management WPI – Prescribing Guide for the Dying Patient using evidenced-based best practice guidelines.

Implementation of the Care Plan for the Dying Person - Commenced in the ED, this care plan supports transition of care and facilitates clinical handover in instances where the patient is transferred to another ward / facility.

Interdepartmental collaboration supporting appropriate and person-centred disposition planning / transfer - Patient preferences (including religious or cultural preferences) are given priority when determining where best to care for the dying patient. Every effort must be made to quickly accommodate the patient in the most suitable area or preferred location for their end-of-life care. Options include:

  • Returning to home / usual place of residence, supported by Palliative Care community follow-up.
  • Admission to hospital / Palliative Care Unit (Dove Palliative Care Unit).
  • Single room in the Short Stay Unit in ED - for those patients who are imminently dying.

Alternative transport for discharge – agreement to utilise the SCHHS Non-Urgent Non-Ambulance (NUNA) vehicle to transport patient home / usual place of residence, to Dove Palliative Care Unit or another SCHHS facility.

Staff survey – SCUH ED staff participated in a survey from The Palliative Care Evaluation Tool Kit: A compendium of tools to aid in the evaluation of palliative care projects. The survey assessed views about death and dying, attitudes towards palliative care and helped direct further training requirements.

Evaluation and Results

  • The project achieved the aim to deliver a standardised pathway for quality care at end of life for patients and carers in the SCUH ED.
  • ED staff have improved their skills and knowledge in managing the dying patient so that appropriate EOLC is commenced and maintained within the ED as necessary.
  • Repeating the staff survey is planned for mid-2019.
  • Formal evaluation using a research framework is being considered in partnership with the university sector.

Lessons Learnt

  • Strong medical leadership is vital to the success of this initiative.
  • Broad engagement of the multi-disciplinary team in a ‘safe’ creative space ensures open discussion, creative ideas sharing and improved collegiate support and understanding of roles.
  • Staff engagement is best achieved when the staff recognise the need and value of implementing a change in process. Staff easily recognised this as a value-add for the patient and their families and the staff involved in their care – not as a process implemented for organisational convenience.
  • Allowing and enabling staff ‘ownership’ of solution design assists in the implementation.

References

Clinical Excellence Division: End of life care: Guidelines for decision-making about withholding and withdrawing life-sustaining measures

Eagar K, Senior K, Fildes D, Quinsey K, Owen A, Yeatman H, et al. The Palliative Care Evaluation Tool Kit: A compendium of tools to aid in the evaluation of palliative care projects. 2004.

Further Reading

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Key contact

Bernadette Nolan
Clinical Nurse Consultant, Clinical Audit and Evaluation
Sunshine Coast Hospital and Health Service
(07) 3646 3494
CareAtEOL@health.qld.gov.au