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Background The Palliative Care population represents a heterogenous group of patients with variable risk factors for bleeding and venous thromboembolism (VTE). Decisions about VTE treatment and primary prophylaxis can be challenging in these patients. Aim The aim of this audit was to evaluate the management of anticoagulation in the hospice, hospital and community settings against current guidelines. The results of this audit, in addition to an extensive systematic review, informed the update of regional guidelines for the management of anticoagulation in Palliative Care Patients. Methods A retrospective case note review was carried out across a regional palliative care network in North West England. Results 189 patient records were analysed across 12 different sites within the region. 70% of patients were in hospice, 23% in hospital and 7% in the community. Of 89 patients on treatment dose anticoagulation, only 9% had the intended duration of anticoagulation documented. Of 60 patients on treatment dose low molecular weight heparin (LMWH), weight was documented in 63%. Renal function was documented in 88% of patients on LMWH, and in 75% of 24 patients on treatment dose direct oral anticoagulants (DOACs). 71% (66/93) had a venous thromboembolism assessment completed. Prophylactic anticoagulation was given in 43% of these 93 patients. For prophylaxis, the majority (90%) received LMWH, with the remaining 10% prescribed a DOAC. 42 patients died during the episode of care. The anticoagulation (either primary prophylaxis or treatment) was continued until death in 43% of these patients. Conclusion Clear documentation of anticoagulation duration, and factors which influence choice of anticoagulant and dose (eg renal function and weight), are important for safe prescribing. These results have influenced the content of a regional guideline to enable healthcare professionals to make effective, evidence-based and patient-centred decisions about anticoagulation in patients with a life-limiting illness.

Background Strong opioid substitution to a different route or a different strong opioid is common in palliative care. Variation in practice had been noted across the region despite the availability of regional, national and international guidance. Aim Within a regional palliative care audit program in the North West of England to; Evaluate opioid substitution practice in hospice, hospital and community settings; Update regional standards and guidelines for opioid substitution. Methods Systematic literature review; Multi–site retrospective case note analysis. Results 18 articles were identified to inform the update of the regional standards and guidelines. 285 patient records were analysed from 21 different sites. Patients had either undergone a change in route or a change to a different strong opioid. In 93% of cases the reason for opioid substitution was documented. The commonest reasons were neurotoxicity (58%), oral route being inappropriate (34%), renal impairment (14%) and inadequate analgesia (12%). In only 35% of cases was the rationale for the new dose documented (eg with a dose calculation or reference to a conversion table). In 21% there was documentation of alternative measures tried prior to the opioid substitution (n=281). The commonest alternatives were: treating adverse effects with medications (43%), using co-analgesics (38%), checking for drug interactions (18%) and making a dose reduction (16%). The opioid substitution was of clinical benefit (complete or partial) in 87% (n=52). Conclusion This study showed that strong opioid substitution was of benefit in the majority of patients. However there is risk involved in any opioid substitution. Clear documentation is critical to justify clinical decision-making. It is currently not widespread practice to be documenting rationale for the new dose of the strong opioid. This is now recommended in the updated regional guidelines.

Background Bereavement is defined as the state of a loss when someone close to you has died. It is important that people closely affected by a death are communicated with in a sensitive and timely manner and that those at risk of pathological bereavement reactions are identified and supported. At a tertiary cancer centre it was recognised that families need time and support soon after the death of their loved one. Aim To deliver a ‘day after death’ service providing personalised bereavement support to families/carers and learn lessons about care by discussing their experiences. Methods At our tertiary cancer centre we implemented an innovative 4 step approach to supporting bereaved families and carers: Comprehensive documentation including a bereavement risk assessment at the time of death. Innovative ‘day after death’ service. Post bereavement contact if accepted. Face to face follow up where required. The bereaved families/carers meet with a senior member of the Nursing Team who knew the patient on the next working day. They meet in a private room away from the wards and discuss how they are coping with their loss and listen to any questions/concerns they may have. The relevant paperwork is then provided. This also provides the opportunity to follow up the bereavement risk assessment undertaken by the ward staff. Following the meeting a reports is shared with the Director of Nursing and discussed at the Trust Executive meeting. Results There have been 84 deaths within the tertiary cancer centre in the last 12 months. All bereaved families/carers have received the day after death service. This has enabled us to provide comprehensive and personalised bereavement care. It also enables us to identify those people likely to have complex bereavement and signpost to local specialist support services. Conclusions We have successfully implemented a 4 step innovative service delivering personalised bereavement care.

Background Strong opioid substitution to a different route or different opioid is common in palliative care. The dose of the substituted opioid should be an individualised clinical judgement but accurately calculating the equianalgesic dose is a key step in safely prescribing the new opioid. Variations in professional practice had been noted across the region. Aim Within a regional palliative care audit program in the North West of England to; Evaluate the opioid substitution practice of healthcare professionals (HCPs) in hospice, hospital and community settings; Update regional guidelines for opioid substitution. Methods Systematic literature review; HCPs working in palliative care who prescribe or recommend medications. Results 18 articles were identified to inform the updated regional guidelines. 82 HCPs from 24 clinical sites completed an online survey of practice. 100% of respondents (n=78) reported Morphine is their oral strong opioid of choice. 95% (n=73) reported Morphine or Diamorphine is their parenteral strong opioid of choice. Reported conversion ratios compared with equianalgesic ratios recommended by regional guidelines: Morphine oral to Morphine subcutaneous: 95% use 2:1 (vs 2:1 recommended). Morphine oral to Oxycodone oral: 67% use 2:1, 25% use 1.5:1 (vs 1.5:1 recommended). Oxycodone oral to Oxycodone subcutaneous: 71% use 2:1, 26% use 1.5:1 (vs 1.5:1 recommended). Morphine oral to Alfentanil subcutaneous: 59% use 30:1 (vs 30:1 recommended). 35% consult equianalgesic table or guidelines. Conclusion When converting Morphine to Oxycodone or oral Oxycodone to subcutaneous Oxycodone the majority of HCPs used a 2:1 conversion ratio, rather than the 1.5:1 ratio recommended by regional, national and international guidance. This may lead to higher than recommended doses when converting Oxycodone to Morphine, subcutaneous Oxycodone to oral Oxycodone or Oxycodone to Alfentanil. Further work is required with stakeholders across the region to increase awareness of this.

Background: Enhanced supportive care (ESC) promotes the earlier implementation of supportive care within cancer care. While earlier supportive care has been demonstrated to improve patient outcomes, the model of delivery is variable. The Clatterbridge Cancer Centre has developed a multi-professional delivered model with clinical nurse specialists providing ongoing patient review and care. Method: A retrospective single-system design was used to assess longitudinal changes in Integrated Palliative Care Outcome Scale (IPOS) scores as indicators of quality of life. For other outcomes, a retrospective case control analysis was undertaken. Results: Statistically significant improvements in all IPOS scores were observed for patients attending ESC. Compared to controls, quantitative outcomes included prolonged survival and reduced chemotherapy-related mortality. Multi-professional delivered ESC successfully improves quality of life and outcomes.

The Serious Illness Care Programme is a complex intervention developed in the US to improve communication between clinicians and patients with serious illness. In collaboration with Aridane Labs the programme has been developed for use within the UK, with pilot implementation funded by NHS England. Within the programme, clinicians are trained in use of a Serious Illness Conversation Guide (the guide), to structure conversations with patients/families. A feasibility of the UK programme is underway, within one North West cancer centre. Aim To present interim results from the feasibility study Methods Data on the use and experience of the UK programme, from the perspective of clinicians and patients Quantitative Data: Questionnaires: Clinicians – pre/post training: confidence; attitudes to care of the dying; acceptability of serious illness care programme Patients – pre/post serious illness conversation: Quality of clinical communication; Quality of life; Anxiety; depression. Qualitative Data: In depth interviews: Clinicians: experience of the UK programme, education and training and engaging patients in serious illness conversations Patients: experience of engaging in serious illness conversations, including their acceptability of the approach Results Quantitative Data: Results will be presented to assess the feasibility and acceptability of the UK programme: Proportion of patients identified conversations and participation in study measures Illustrate any indicative improvements in communication and patient outcomes. Qualitative Data: Thematic Analysis to explore perceptions and experience of the programme: results will highlight main themes, such as: Conversation Value; Holistic and Compassionate; Opening up conversations with family members; Breaking the ice; Timing of conversation and Prognosis. Conclusion Results from this study suggest these conversations promote shared decision making and individualised care planning, and espouse 9holistic9 and 9person centred9 care. Further research and evaluation is required to understand the effect of the UK programme on patient outcomes.

Background In 2014 the family of a woman who died in one of Britain’s best-known hospitals won their legal claim that her rights were violated when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) document was completed without her or her family being consulted. A judicial review noted that Article 8 of the Human Rights Act was breached, concluding that there is a duty to consult patients and/or those important to them in relation to DNACPR unless that consultation may result in physical or psychological harm; this is more than just causing distress. Aim Audit practice regarding DNACPR decisions and the discussions surrounding them in a tertiary cancer centre. Methods A retrospective case note review of patients‘ in whom a DNACPR had been placed was conducted in December 2016. Practice was compared against the 2016 Joint Statement, ‘Decisions relating to cardiopulmonary resuscitation’. Results 22 case notes were reviewed in which a DNACPR was completed; 19 due to futility in cases of terminal cancer and 3 due to patient choice. In 3 cases no consultation had taken place. The reasons for this included patient/family declining a discussion and risk of harm. In 4/22 cases there was no documentation of the clinical reasoning for a DNACPR decision. In 1 case the consultation led to potentially avoidable patient distress. In 7 cases the patient lacked mental capacity to participate in a consultation; in 1 case it was felt it would cause too much harm to discuss the decision with their family. Conclusion Patients and those important to them should be made aware of DNACPR decisions and these conversations recorded, including reasons for the decision. This audit however has highlighted ongoing variability in practice. Further training is needed in order to standardise practice and ensure high quality consultations around this sensitive topic are undertaken.

ObjectiveTo describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values.MethodsWe present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP).ResultsFive sites across the USA and England described their individual experiences implementing patient selection as part of the SICP. They employed a combination of clinician screens (such as the ‘Surprise Question’), disease-specific criteria, existing registries or algorithms as a starting point. Notably, each describes adaptation and evolution of their patient selection methodology over time, with several sites moving towards using more advanced machine learning–based analytical approaches.ConclusionsInvolving clinical and programme staff to choose a simple initial method for patient identification is the ideal starting place for selecting patients for palliative care interventions. However, improving and refining methods over time is important and we need ongoing research into better patient selection methodologies that move beyond mortality prediction and instead focus on identifying seriously ill patients—those with poor quality of life, worsening functional status and medical care that is negatively impacting their families.

Background Grief is a natural response to the loss of a loved one but can have the potential for long term adverse effects. Bereavement services are therefore essential to provide support and to identify those at risk of harm. A ‘day after death service’ for bereaved persons is a longstanding component of bereavement care at our tertiary cancer centre. Bereaved persons are met by a clinical nurse specialist the day after the death for a face to face discussion and support needs assessment. This system aims to improve support and identify those at risk of pathological grief reactions. Aim Conduct a quality improvement project aimed at enhancing bereavement support at our centre by incorporating feedback from bereaved persons into trust-wide education and care quality indicators. Methods A 12 month retrospective audit was undertaken to evaluate bereavement service outcomes.This was combined with feedback from stakeholders to develop a PDSA quality improvement cycle. Results At baseline 51 deaths were recorded in 12 months. 42 people agreed to ongoing support following accessing the day after death service. 39 people did not require any further support following a single phone call. Three bereaved persons needed additional support due to prolonged/pathological grief, and were supported appropriately. Stakeholder satisfaction surveys revealed an 88% approval rating for emotional support and practical help, and 100% would recommend the service to others. Qualitative constructive feedback suggested enhancing methods of detecting people at high risk of pathological grief and developing an action-orientated approach to bereavement support. Conclusion Bereavement care incurs practical as well as emotional challenges. Despite positive feedback regarding the emotional support provided by our service, there are practical areas for development. The next step of our project is to incorporate these changes into education and information processing tools, before re-evaluating progress.