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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.

Care in the terminal phase is an important part of medical practice. Ensuring a dignified death for patients with appropriate support for carers is a core activity of all healthcare professionals. Once a patient has entered the dying phase it is important that pain and symptom control is managed appropriately. All medication that needs to be continued should be converted to the subcutaneous route. As required medication should be prescribed for the key symptoms that occur in dying patients, i.e. pain, agitation, respiratory tract secretions, dyspnoea, and nausea and vomiting. Futile treatments should also be discontinued at this time and consideration should be given to the discontinuation of antibiotics and blood tests. Normally a decision for a ‘Do Not Resuscitate' order is made at this time. Appropriate communication both with the patient and their family is key, both to ensure that the psychological and spiritual needs of the patient are met and that the family is aware that the patient is dying. Decision-making and practice for care of the dying can be supported by use of the Liverpool Care Pathway for the Dying Patient.

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.

Introduction Epidural analgesia is useful for some patients with refractory cancer pain. However delivering a continuous epidural infusion can raise some challenges regarding safety and practicality. We present our experience of using the Accufuser Elastomeric Vacuum pump. Aims ▶To identify a delivery method for continuous epidural infusion for ambulatory patients in the Hospice and Community setting. ▶To develop policies and procedures and facilitate staff training. ▶To facilitate discharge of ambulatory patients with continuous epidural infusions. Methods The Integrated Pain service performs joint consultations and has monthly meetings to develop Policies and Procedures and discuss complex cases. In response to patient need we performed a literature review to select a device that was portable, light, easy to fill, has long duration of action and was safe. We met with the manufacturer to evaluate it fully prior to use. Result The Accufuser is an elastomeric device delivering a near linear infusion with a patented piston preventing under or over dosing. It has variable infusion rates and volumes. It is filled aseptically in the hospital pharmacy in the aseptic unit and we used a device which lasts 5.7 days. It was used for a patient with severe perineal pain despite maximal tolerated oral therapy who had benefitted from bolus epidural analgesia. Following titration of diamorphine, clonidine and levobupivacaine the patient was discharged and returned to the hospice for renewal. Discussion Introduction of the accufuser required an integrated approach from the Pain team, Pharmacy and the Specialist Palliative Care Team. Development of a policy and patient leaflets alongside intensive staff training was required. We feel this is innovative practice and opens up the choices for Units and Pain teams dealing with Epidural infusions. This device is unique in its mechanism and patented technology and offers a better patient experience.

Introduction While risk management is an integral component of high quality care it can be difficult to demonstrate effectiveness. A key aim of the Hospice Business Plan was to devise and develop a Risk Register that could incorporate Fundraising and Clinical activities as part of an Integrated Governance Framework. Aims ▶To produce a Risk Register to identify areas and work practices most at risk ▶To implement a Risk Register to minimise risks that could affect the running of the Hospice ▶To use a Risk Register to monitor effectiveness of actions/initiatives. Methods ▶Literature review ▶Risk Matrix ▶Risk scoring process ▶Audit cycle. Example Risk Date Governance Area Description of Risk concern (x,y,z) Potential Impact including current controls Risk Score (Pre) Risk control processes to reduce or transfer risk Date for completion Risk Score (Post) Likelihood rating Impact rating RISK. Clinical effectiveness Administration of bisphosphonate infusions without adequate checks causing harm Patient condition compromised Develop hospice policy on bisphosphonate infusions with flow chart Training and education for nursing and medical staff Distribution of new regional audit guidelines Audit to check on process Results ▶Organisational risks were identified and scored using likelihood and impact ratings ▶Risks were categorised into seven key themes ▶Potential impact including current controls were described ▶Risk control processes to reduce/transfer risk were shown for each individual risk ▶Following intervention 86% of high risks were significantly reduced within a 7 month period. Conclusions ▶Use of a Risk Register clearly demonstrates effectiveness ▶Heightened awareness; risk is everyone9s business ▶Audit has shown improvements in identifying risks ▶Strengthened communication across fundraising and clinical services. Recommendations ▶Understanding of Risk Register to be part of induction training ▶Use of Register needs to be an ongoing process and should be regularly monitored and updated.

Background An increase in the complexity of patient9s admitted to the Hospice and a greater use of acute interventions had resulted in staff feeling “too busy to care” with less time to provide high quality care . We recognised the need to change working practices to improve patient experience and staff satisfaction. After reviewing possible models and undertaking a scoping exercise, we agreed to implement the NHS Releasing Time to Care : The Productive Ward as a recognised quality initiative. This was previously restricted to hospital and community use, designed to help teams review working practices and minimise inefficient systems. This was supported at Network level in collaboration with 5 other Hospices. Aims Increase Time for Caring therefore improving patient experience Improve departmental/inter-departmental communication Improve patient /staff environment Improve staff satisfaction Approach used Network support Enhanced team working Staff and senior management commitment Collaborative module implementation training Phased roll out Evaluation at steering group level Outcomes Confirmed network funding in conjunction with other hospices Network training and support to empower staff Focus on collaborative approach, shared learning experience, making a wider impact than working in isolation Transparent care provision using quality measures Efficient staff working practices Cost effectiveness, efficient use of limited resources Improvement in communication across all services and local hospices Awareness of the importance of environment; little wins to improve patient care have a positive effect on staff morale Improved patient safety and standard of care evidenced by quality measures Benefit at local, organisational and network level Application to Hospice Practice Improved collaboration and networking Useful toolkit that has impacted on time for caring making a difference to patient experience and staff satisfaction Transferability Supports integrated working

Background The GSF was developed in 2000 to improve palliative care in primary care. National dissemination was facilitated through a cascade approach with a Central Team supporting local facilitators. GSF has been shown to improve:- 1. Quality of care 2. Co-ordination and communication 3. Patient outcomes and cost effectiveness. Acute hospitals have been described as the missing link in providing seamless, co-ordinated high quality end of life care. At present there has been no experience of implementing GSF into a tertiary cancer centre. Identification of patients in the last 12 months of life was recognised to be challenging for staff. Aim To analyse the knowledge and skills of health care professionals working in a tertiary cancer centre in identification of patients in the last twelve months of life and the use of advance care planning tools. Method Three questionnaires were distributed to health care professionals 1. A base line survey assessing the knowledge and skills of health care professionals recognising patients in the last twelve months 2. An organisational questionnaire assessing the knowledge of the senior managers 3. An after death analysis for deaths within the Centre Results The baseline questionnaire was distributed to 152 staff. The response rate was 76%. The organisational questionnaire was distributed to 3 wards and the Head of Nursing. The Response rate was 100%. The After Death Analysis examined 86 deaths in the Trust Complete results from the three questionnaires will be presented with details of the subsequent action plan Conclusion Interim results from the surveys have demonstrated that healthcare professionals require further training in the identification of patients at the end of life and the use of advance care planning tools. A comprehensive education package delivered over 6 months will aim to address the needs of staff.

Background The GSF was developed in 2000 to improve palliative care in primary care by improving :- 1. Quality of care 2. Co-ordination and communication 3. Patient outcomes and cost effectiveness. Acute hospitals have been described as the missing link, providing seamless, co-ordinated high quality End of Life care. Enabling staff to identify patients in the last 12 months of life in a systematic sustainable way and linking this into discharge planning proves difficult. There has been no experiences in implementing GSF in Tertiary Cancer Centres, this causes many challenges; around communication with multi-disciplinary teams across a large geographical area. Aim To improve engagement of staff in identifying patients in the last 12 months of life. Method RAG is a tool used for highlighting patients needs, referrals and outcomes to aid in a safe/timely discharge. RAG (Red/Amber/Green) boards have been implemented as part of the discharge planning. It9s regarded as a good way of engaging colleagues in the identification of patients within the last twelve months of life. Results A weekly meeting is held on all wards. Staff discuss and agree the expected prognosis for individual patients. Each category is linked to specific needs which are addressed. Blue=Stable disease Green=Less than twelve months Amber=Weeks prognosis Red=Days prognosis The visual aide memoir assists all health care professionals to review the needs of individual patients ensuring appropriate support is in place for both patients and carers at the time of discharge Conclusion The GSF can be linked with the discharge planning process in an acute hospital setting. This facilitates discussion and ensures the needs of patients are addressed and met in a timely manner. Appropriate communication with primary healthcare teams is achieved with collaboration and seamless care across healthcare settings becomes a reality.

Background Advance Care Planning is a process of discussion with individuals about their wishes and preferences regarding the type of care they would wish to receive or refuse in the future, should they lack capacity at that time. These discussions need to be handled with sensitivity and skill, the outcomes documented and reviewed regularly, and communicated to other relevant people with the individual9s consent. The recognition of the importance of Advance Care Planning has been highlighted by the National End of Life Care Programme. As a UK tertiary cancer centre serving a population of 2.3 million, the implementation of Advance Care Planning produced significant and unique challenges. Aim To introduce Advance Care Planning into a tertiary cancer centre. Method Education was delivered to all health care professionals in both formal and informal sessions, including 9drop in9 sessions provided over a whole day. Resource folders were introduced into all wards, containing written information for staff, and localised information and documentations for patients. Results There was good attendance from staff across the organisation and the formal sessions stimulated much discussion especially regarding the role of a tertiary centre. These discussions included the inherent difficulties involved in liaising with a range of health care professionals across the region. There are multiple Health Care Teams in the Network, all of whom are at different stages of implementing Advance Care Planning for their patients. It was agreed that sensitive communication with the patient was of the utmost importance, with some staff admitting their lack of confidence in this area. Conclusions The introduction of Advanced Care Planning into a tertiary cancer centre is a challenge due to the wide geographical area. Further education sessions are planned including an intermediate experiential two-day communication skills training course to help staff required to initiate sensitive discussions with patients.

Background The author works in a tertiary centre in the UK, caring for over 7,000 new patients per year. Carers play a central role in providing support to patients. However, many carers do not experience a cohesive integrated system of social support. Optimal input for carers will depend on a comprehensive assessment of the situation and their needs. Aim To develop an assessment tool that can be used by all health care professionals to assess the carers9 needs and provide appropriate intervention to support the carers. Method A multi-professional group was set up to establish the baseline needs of carers. The assessment and documentation of carers9 concerns and needs was evaluated using the documentation recorded on the Trust9s electronic system. The Cancer Centre joined a major research project untaken by a local university and another NHS Trust to develop an assessment tool for carers who care for palliative patients. Staff took part in an on-line questionnaire to prioritise the issues they feel result in an increase in carer stress which could affect their ability to provide care. Results The research showed that carers9 concerns and needs were not being formally assessed. From the information collated a draft Carers9 Needs Assessment Thermometer was produced and piloted to carers. The evaluation from carers and health care professionals who have used this tool will help finalise the tool which can be used for carers. Recommendations Carers9 Needs Assessment Thermometer will be used at the Cancer Centre to assess the needs of carers supporting palliative care patients. The tool will be used in conjunction with a carers9 directory which was also developed at the Cancer Centre, which gives information on advocacy support, carers9 allowance, national support organisations and supported is available in the carer9s area.

Introduction Nurse-led clinics are recognised as an important part of health care provision as service demand across the UK continues to escalate. The End of life Care Strategy recommended that all palliative care patients should have access to rapid specialist advice and clinical assessment. Cancer centres cover wide geographical areas. Patients attending for treatment are often unable to access their local palliative care services. This can lead to inadequate assessment/management of physical, psycho-social and spiritual problems. Aims 1. To ensure that patients attending for cancer treatment have access to appropriate, timely specialist palliative care 2. To improve liaison with other healthcare professionals and provide support/information. 3. To ensure seamless co-ordinated care by excellent communication with local palliative care teams. Method A twice weekly nurse-led palliative care clinic was set up in a cancer centre with clear referral criteria. Joint reviews with nursing/ medical colleagues were encouraged. There was input available from a Consultant in Palliative Medicine. Clinic letters were produced and faxed at the end of each review. Evaluation forms were sent to all healthcare professionals. Results Clinics run for two hours. 180 patients have been reviewed over 18 months. An increasing number of joint reviews have been undertaken. Flexibility is key as 50% of referrals are seen as emergencies. 93 % were for pain/ symptom control. 70 % for psychological support 30% were for spiritual support. 50% of referrals came from medics, with 50% from clinical nurse specialists. The majority of patients were managed as out-patients. 25% required admission to the Unit. A full breakdown of clinic activity and outcomes will be available in the final report. Conclusion Nurse-led clinics are an excellent way of delivering care to patients attending a tertiary cancer centre. Improved joint working and creation of educational opportunities are also significant benefits of the service.

Background In recent years, there has been growing recognition that the needs of dependent children should be considered when dealing with a parent with a life-threatening illness, Much patient distress can be associated with worries about the children and also, many children welcome the opportunity to talk with parents or professionals about the illness, treatments, survival and coping strategies. Many Hospices/Palliative Care Units in the UK provide support for dependent children, however, there is very little face-to-face support at diagnosis or subsequent care, in the acute setting. Aim To provide an individualised service for families and children, depending on age, stage of development, family values, patterns and culture, from diagnosis to bereavement. Method During the past five years, this tertiary Cancer Centre has provided a family service for patients with children. There is a weekly specialist service where patients can discuss the needs of their children or can access individual support for the children themselves. Parents are helped to discuss issues with their children and provided with resources such as leaflets, books, internet sites, discussion of memory boxes and DVDs. Some children may prefer to talk to a professional on their own or with a family member/friend. They are encouraged to ask questions about what is happening, look at options for support and have a point of contact if they wish to return at any future date. Results Patients and their families have benefitted from support in all stages of their cancer journey. Education and advice has been available for generalist staff and support has been augmented by the Specialist Palliative Care Team. A wide range of resources for children and their relatives are available in the Unit.

Background It can often be difficult for audit to make a sustained difference to clinical practice across and between organisations. The Merseyside and Cheshire Palliative Care Network Group was initially formed in 1995 and consists of individuals involved in specialist palliative care across the network who are based in community, hospice and hospital settings. The strength of the group lies in the multi disciplinary representation and the on-going enthusiasm of the various teams to participate in the projects. Method There are bi-monthly audit meetings with five audits and one planning session each year. The audits are a combination of new audits, regional audits (which look at previously audited topics) and non symptom control subjects. Results Each meeting attracts approximately 60 healthcare professionals plus an external expert. The presentation includes a literature review, audit results and a discussion around standards and guidelines. Regional audits complete the cycle by assessing group performance against previously developed standards. Dissemination is achieved at national and international level. Every 3 years, the guidelines are collated into a book which is part of the core formulary for the Network. It is now in the 4th edition and contains 43 different topics. Each chapter is referenced with levels of evidence and grades of recommendation. Conclusion The book acts as a resource for professionals and is applicable to those caring for cancer patients and other forms of advanced disease. It encourages the setting and monitoring of standards in palliative care and through the audit programme promotes clinical excellence in end of life care.

Background Trainees in Palliative Medicine in the Mersey Deanery require experience of a variety of work settings during training which leads to them being scattered within the region. Some services have only one trainee and there are few opportunities for the trainees to meet. Regular contact between trainee colleagues provides the benefit of peer support in an emotionally challenging specialty. Informal discussions and exchange of clinical and educational information can be maintained and there are opportunities to discuss new developments within the specialty with colleagues at a similar level to oneself. In the current economic climate UK health chiefs are striving to reduce cost in all areas of healthcare including study budgets and trainees must be creative in their efforts to fulfil their curriculum requirements. Addressing the problems: To enhance the educational and supportive contact between trainees, an online electronic learning platform has been developed specifically for Mersey Deanery Palliative Medicine trainees. The platform used is Moodle, a free and open-source virtual learning environment. Trainees have a personal login and password and are then able to access: • Links to resources and websites covering the Palliative Medicine curriculum and e-portfolio • A monthly journal club • Fora for discussion of challenging anonymised clinical cases and provision of peer support. • A revision area for trainees sitting the specialty examination • Calendar marking important dates for trainees Progress Report: The website is used regularly. Trainees have more contact with each other than previously and trainees in different locations are participating in online clinical discussions. There are over 200 trainee activity logs per month across the site and there have been over 2800 activity logs since the site was set up in March 2011. Formal evaluation will take place at the end of the first year of the site9s use.

Background Continuous epidural infusions are often delivered by pumps that require changing every 24 h. This limits patient independence and quality of life and provision in the community can be difficult. Alternatives can be extremely expensive with limited availability for example, implantable devices. Methods The Accufuser Elastomeric Vacuum Pump device delivers a near linear infusion with a patented piston over 5.7 days. The infusion can be prepared aseptically in the Pharmacy department. Discussion/Results This report describes the challenges and benefits of implementing a new approach to delivering epidural infusions in four patients. The device has been tolerated well, and used on four separate occasions. Longest duration of use was 14 weeks and is on-going. Robust device which is lightweight, easy to manage and does not depend on batteries. Good evaluation from patients. Easy, flexible drug titration. Combination of drugs can be varied according to compatibility studies. Change of device is managed easily by staff following appropriate training. The device is cost effective and allows patients to maintain mobility and independence. It has been accepted by community staff. This device has no significant safety issues or complications.

Background Current NICE Guidelines recommend that acute hospitals should provide access to face to face specialist palliative care assessments, 9 am–5 pm, 7 days per week. Continuity of specialist palliative care input is also highlighted in the End of Life Care Strategy. Tertiary cancer centres are often considered to have higher levels of palliative care skills among medical and nursing staff. The impact/need of a 7 day week specialist palliative care service is unclear. Clatterbridge Centre for Oncology, a tertiary cancer centre, has provided a 7-day service by Clinical Nurses Specialists (CNS) since April 2011. Aim To evaluate the impact of 7 day face-to-face access to specialist palliative care, and to explore how the service is valued and used by oncology staff. Method A questionnaire was sent to 120 medical and nursing staff. Results The response rate was 48%.Two-thirds of staff had used the service, with 95% finding it very helpful. Pain management was the most common reason for requesting advice (35 occasions). Further common reasons for referral included opioid toxicity, agitation and care of dying patients. Other reasons included chest secretions, vomiting, psychological/spiritual care, and family/carer support. The service was used 1–5 times by 80% of staff, and 6–10 times by 11% of staff. However, 6% of staff used the service on more than 10 occasions. All staff found the CNSs to be accessible (very=88%, quite=12%). The service was considered to be very important or important by 96% of staff. Qualitative information demonstrated that the service was seen as crucial, excellent and was highly valued. Conclusion This survey demonstrated the need for the service in a regional oncology centre and that it was valued by both medical and nursing staff. The survey also provided information for areas requiring further educational input.

Background The National Institute of Clinical Excellence emphasise that, ‘People with incurable illness should be able to make choices about care at the end of their life and this includes a choice about where they die.’ The logistics of arranging a rapid discharge for a dying patient from a tertiary cancer centre serving over 2 million population can seem to be an overwhelming challenge for staff. A multi professional working group based at Clatterbridge Centre for Oncology developed and implemented a Rapid Discharge Pathway following close liaison with services and personnel across the Network. Aims of Study To evaluate the effectiveness of the Rapid Discharge Pathway for the Dying Patient o To resolve emerging challenges associated with emergency discharges at the end of life to a large geographical area. Method A retrospective audit was completed over a pilot period reviewing medical case notes and pathway documentation. Discussion Seven patients requested a rapid discharge at end of life with an age range of 23–71 years. Six were successful and one was cancelled due to a rapid deterioration in condition. The study demonstrated the effectiveness of a procedure to ensure discharge medicines were rapidly available and appropriate equipment was in place. There was good communication with families and other healthcare professionals. Challenges included ambulance availability and out of hours discharges. Innovative ways to resolve difficulties are described and the possibility of escorted discharges is explored.

Background The National Institute for Clinical Excellence recommended that Cancer Networks should provide 24 h access to specialist palliative care telephone advice. The Manual of Cancer Services 2004 suggested that a telephone advice service should be available to core members of cancer MDTs. Clatterbridge Centre for Oncology is a tertiary cancer centre with more than 7000 new patients every year. A specialist palliative care service is available 7 days per week 9–5 but the 24 h access is provided by an informal arrangement with a single clinician. Healthcare professionals working in tertiary cancer centres often have an increased knowledge of palliative care and it has been suggested that 24 h access to specialist advice may not be as important as for district general hospitals. Aim To explore the views of healthcare professionals working in a tertiary cancer centre about the need for 24 h access to specialist palliative care advice. Method A questionnaire was distributed to healthcare professionals in a tertiary cancer centre asking for their views on: areas of concern use of current informal advice provision impact of advice on patient care. Results The questionnaire was distributed to 129 staff. The response rate was 47%. In the previous 4 weeks advice had been required on 46 occasions. 54% of staff had requested advice. 97% found the advice very helpful.100% felt that the advice had a positive impact on patient care. Conclusion This survey demonstrated that staff in a tertiary cancer centre had palliative care educational needs and valued access to specialist palliative care advice believing that it had a positive impact on patient care.

Background A syringe pump is a portable battery-powered device used to deliver a Continuous Subcutaneous Infusion (CSCI), and is used in the delivery of subcutaneous medication to patients in order to optimise symptom control. A tertiary cancer centre can experience huge challenges when transferring patients to alternative care settings as the distances to be covered can be great, and the time taken for the patient to travel can be considerable. At Clatterbridge Centre for Oncology, the system for transferring patients receiving medication via a CSCI was inadequate, as the CSCI would be discontinued and the patient9s symptom management could be compromised during the journey. This is especially important during end of life care when a patient is being discharged in the final few days of life. Aim To develop a process where patients could be transferred to an alternative care setting with a pump in situ in order to maintain an optimum degree of symptom control during the patient9s transfer, with no disruption to medication delivery. Method Five pumps were designated specifically as transfer pumps. Documentation was designed to track the pumps and to monitor their return. A padded addressed envelope is sent with the pump for return, with accompanying details for the receiving healthcare professional regarding discontinuing the pump. Results Syringe pumps were used for the transfer of palliative care patients on 42 occasions, with 6 being used for patients who were on a rapid discharge home for the dying patient pathway. All patients suffered no disruption to medication delivery. Conclusion This innovative system of transferring patients with a syringe pump in situ to maintain an optimum degree of symptom control has been very successful. Staff found the process easy to use, and there was significant benefit to patients.

Background Senior clinicians and managers are at the forefront of innovation within Palliative Care. This places significant demands on professionals who need specific skills to maximise their effectiveness and their impact in the clinical workplace. Merseyside and Cheshire Cancer Network funded a Leadership Impact Programme for Consultants in Palliative Medicine. This links leadership style directly with engagement, wellbeing and performance which in turn helps individuals to encourage change and innovation in their organisation. Method Diagnostic management tools, participation in a coaching centre with feedback, development workshops, and peer support. Subsequent Action Learning Sets over 12 months then facilitated participants to use their skills to produce change and innovation in their workplace. Discussion/Conclusion The course was designed to meet the needs of the individuals and the group in general. Participants included seven senior clinicians and two senior clinical managers Evaluations were extremely positive with many specific examples of how learning and experiences from the course had impacted on clinical services across a range of organisations. 100% of participants felt the programme had met their personal objectives either very well or completely. All reported a marked improvement in strategic awareness and ability to influence. Results included enhanced team development and leadership leading to integration and improved communication; ability to deliver significant change in an organisation; sharing of new ways of tackling challenges and the commitment to collaborative ventures which were both cost effective and innovative The success of the programme has encouraged the Network to support a second 12 month course for a further cohort of senior clinicians.

Introduction Transdermal opioids such as Fentanyl and Buprenorphine are recognised as effective analgesics in the treatment of moderate to severe pain in patients with both malignant and non-malignant disease. However there is evidence to suggest that the knowledge of appropriate indications, pharmacokinetics, and dose equivalencies of transdermal opioids is poor, particularly among non-specialist prescribers. This is supported by drug safety alerts from the Medicines and Healthcare products Regulatory Agency highlighting reports of life threatening adverse effects and even death from unintentional overdoses. Aim To explore the prescribing patterns of transdermal opioids in palliative care patients in a UK Cancer Network. Methods A prospective audit was conducted over a 6 month period at 3 different sites. This incorporated palliative care patients in hospice, hospital and community settings. Data was collected following the initial specialist palliative care assessment of patients already prescribed transdermal opioids at the time of referral. Information was recorded relating to the original prescriber, documentation of indications, evidence of toxicity and use of breakthrough medication. Results A total of 50 case notes were audited. Key findings revealed that indications for the use of transdermal opioids were only documented in 26% of patients. Over a quarter of patients had evidence of adverse effects, mainly opioid toxicity. The toxicity correlated with the strength of the transdermal opioid preparation rather than incorrect prescribing of breakthrough medication. However, results also showed that there appeared to be a lack of understanding as to appropriate doses of breakthrough medication. Conclusion There are clear situations in which transdermal opioids can be effective and well tolerated alternative step 3 opioids. However these audit results would suggest that there is a need for more education and training particularly among non-specialist prescribers in order to ensure the safe prescribing and administration of transdermal opioids.

Cancer patients have a 1 in 200 risk of a venous thromboembolic event, which is five times higher than the general population. Low molecular weight heparins are used in the treatment of venous thrombo-embolism but a patient weight calculation is required to determine the correct dose. Incorrect weight estimations can lead to serious adverse effects. In general hospices do not have ways of accurately assessing patient weight. Recent guidance from the National Patient Safety Agency has specified guidelines on treatment. Aim To assess hospice compliance with recommendations from the NPSA. To initiate appropriate changes in clinical practice relating to prescribing of LMWH. Method Retrospective audit of clinical records of patients who were on treatment for venous thrombo-embolic disease. Results ▶5/6 patients with venous thrombo-embolic disease were anticoagulated ▶0 patients were weighed prior to treatment ▶Limited use of biochemical screening prior to treatment ▶Incomplete documentation/communication to other healthcare professionals. Conclusion ▶If weighing equipment not available other methods of assessing patient weight are required ▶Essential information should be documented and communicated when patient care transferred to another setting ▶Discussion of the pros and cons of anticoagulation should be part of routine care for all patients. ▶Need for education for all hospice staff ▶Review of documentation used ▶Need for reaudit within 6 months.

Introduction The care of patients with advanced illness is now shifting into the community setting. As a result general practitioners will provide the majority of care for these patients but often lack the confidence and experience to deal with increasingly complex problems. Local GPs identified the need for education in palliative care. However workload can make the provision of education in an acceptable format with good attendance can be a challenge. The aim of this educational initiative was to offer an up to date, relevant and enjoyable course for doctors which improved knowledge, developed skills and influenced practice. The format was also designed to develop closer working relationships between specialists and generalists. Method of delivery A survey was conducted among local doctors asking for opinions on the need for palliative care education and optimum methods of delivery. The resulting education course was delivered by specialist palliative care professionals one evening a month for 6 months. Each session focused on a different aspect of symptom control and included pain, vomiting, emergencies, agitation, depression/anxiety/dyspnoea. A seminar was followed by small group workshops for case discussion. Results 42 doctors registered for the course and 75% attended all 6 sessions. There was evaluation of individual sessions and the course as whole. Results for relevance and appropriateness were excellent. Each session influenced practice for the majority of delegates and fully met the expectations of the participants. The course allowed extensive networking and has resulted in closer working relationships. Conclusion There is a demand for education in symptom control among generalists working in the community. Traditional ways of delivering education can be extremely successful in terms of acceptability and impact. Consultation with local practitioners is key in providing a successful education initiative.