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Background: Integration of care between palliative care and oncology can improve patient outcomes and is increasingly recommended. Enhanced supportive care (ESC), led and delivered by palliative care clinical nurse specialists, is a potential model to achieve this but evidence about it is lacking. Aim: This research aimed to evaluate a nurse-led integrated ESC model within hepatopancreatobiliary cancer care. Method: Some 101 patients with hepatopancreatobiliary cancer were supported by integrated ESC delivered in a co-located clinic. Data on symptoms and quality of life were collected prospectively. Survival data and chemotherapy use were retrospectively analysed following minimum follow-up, using a matched control technique. Results: Patients receiving ESC exhibited less severe symptoms and better mood over time. They also had less aggressive treatment towards the end of life, receiving 31% less chemotherapy than controls with comparable survival. Conclusion: An integrated, nurse-led ESC model can be effective in improving outcomes for patients with hepatopancreatobiliary cancer.

ObjectiveThe anticipatory prescribing of pro re nata medications and continuous subcutaneous infusion (CSCI) medication is essential for the timely management of symptomatic patients at the end of life. There is no evidence to support the safety or appropriateness of anticipatory CSCIs. In 2013, in response to safety concerns about end of life prescribing in the community, we designed an educational intervention to improve prescribing practices among non-specialist prescribers in this area.Methods: how the study was performedWe performed a safety-focussed retrospective cohort analysis of end of life community prescriptions of anticipatory CSCIs over a 12-month period, 5 years after creating clinical guidelines and embedding a multiprofessional rolling education programme. Medications prescribed and administered for symptom control at the end of life are compared between specialist and non-specialist prescribers in terms of their adherence to best practice guidance.ResultsMedications prescribed were not universally administered and more commonly not administered without specialist input. Prescriptions of higher doses of opioids and benzodiazepines beyond those recommended by guidance were significantly greater within the cohort of patients receiving specialist oversight. The prescription of a dose range did not result in excessive dose escalation. For patients not receiving specialist palliative care, median morphine and midazolam doses did not escalate at all once a CSCI was commenced. All midazolam administrations were safe.ConclusionsThe practice of anticipatory CSCI prescribing and administration can be safe in the community non-specialist setting when supported by clinical guidelines, specialist advice and ongoing multiprofessional education.

Background Anticipatory prescribing of ‘prn’ medication for symptom control is recommended for those approaching the last week-of-life however practices regarding anticipatory prescribing for continuous subcutaneous infusions (CSCI) varies widely. The Gosport Report highlighted risks associated with anticipatory prescribing for CSCI. The Association of Supportive & Palliative Care Pharmacy state the perceived benefit does not outweigh the risks. Methods A network-wide cross-boundary audit was undertaken of the use of CSCIs in patients known to specialist palliative care services. A survey was completed by each service-lead and feedback collated following presentation of results. Results 208 of 347 patients (174 hospital, 49 community, 124 hospice) prescribed medication via a CSCI were recognised as likely to be dying. Drugs prescribed included strong opioids (286) anti-emetics (133), anxiolytics (89), anti-cholinergics (102), anticonvulsants (20) and steroids (6). Median doses of opioids and benzodiazepines were low (e,g, morphine 10 mg CSCI q24h) The CSCI had been prescribed in anticipation in 1/5 of patients across all care settings (hospital 20, hospice 24, community 16). 58% of services/organisations responding to the survey allow prescribing for CSCI in anticipation. Feedback following presentation of results and proposed guideline highlighted two conflicting sets of views and practices: anticipatory prescribing for CSCI as vital to ensure timely symptom control in the dying vs. the view it is unsafe practice, citing incidents/near-misses resulting from lack of clinical assessment of need at the time a CSCI is commenced. This audit reviewed current practice but is unlikely to capture such clinical incidents or ‘near-misses’ where drugs are administered without indication or at high doses. Conclusion There is conflicting practice and opinion surrounding the risks and benefits of anticipatory prescribing for CSCI. This audit did not identify unsafe practice but will not reliably capture incidents or near-misses. Further evidence-based national guidance is required to guide safe practice.

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: 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.

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.