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Introduction: Symptom control is a challenge in severe COPD, causing recurrent admission. Addressing palliative care (PC) needs and advanced care planning (ACP), by an integrated respiratory and PC service, should improve symptom management . Objectives: We sought to increase referrals to PC for the more severe and symptomatic COPD population - by integrating a validated palliative care questionnaire (IPOS) and ACP into the Trust’s COPD discharge package. Methods: Each patient admitted with a COPD exacerbation was graded by GOLD and predicted 12-month mortality. ACP was discussed where appropriate and an electronic care plan (ECP) commenced, accessible to all relevant practitioners in the hospitals and community networks. IPOS was completed and personalised PC referral made on discharge, so patients were channelled appropriately into programmes e.g. our Breathlessness service, led by respiratory physiotherapists in the Hospice - a collaborative working model. IPOS was repeated after an intervention. Readmission, mortality and patient reported outcomes were assessed. Results: 136 COPD patients were admitted June to November 2018: 58 were GOLD C/D, meeting eligibility criteria for PC referral. IPOS identified extent of symptoms and repeat IPOS post intervention showed symptom improvement physically and mentally, with a fall in average physical symptom score from 20.2 to 11.6 (p-value=0.02) and depression and anxiety scores (8.1 to 3.6; p-value 0.01). Conclusion: Severe COPD patients experience an array of symptoms, not just ‘respiratory’. Evaluation by IPOS improves focus on these, leading to more holistic care. Its incorporation into the national COPD audit tool would standardise its use.

Rehabilitative palliative care is a developing field integrating rehabilitation, enablement, self-management and self-care into the holistic model of palliative care. A growing evidence-base suggests that rehabilitation not only delays or prevents deterioration in function but can actively improve physical function irrespective of advance disease. The drive towards rehabilitative palliative care has led to an increase in the application of self-management techniques within hospices but there appears to be a gap in the empirical evidence specific to palliative care. The challenges, possible solutions and anticipated patient benefits of hospices being research active have also been highlighted. In response, palliative care professionals across five hospices formed a collaborative group and planned a phased approach to research. Phase 1 : A literature review (March – May 2016) to establish the evidence-base for self-management in palliative care. This identified a significant gap in evidencing the outcomes of self-management in the palliative population. Phase 2 : A collaborative service evaluation (April – May, 2016) identifying self-management opportunities for patients within the hospices followed by a patient survey on the exercise groups they attended. This suggested that promoting self-management through exercise was both acceptable and beneficial in a palliative population. Patient responses showed exercise: Enabled patients to cope better with their illness Increased their confidence in maintaining/improving activity levels Provided a focus for independent goal setting Facilitated independent activity outside of the organisation. Phase 3 : The work is being written up for publication to contribute to the evidence-base supporting the beneficial effects of self-management through exercise and the potential this has to improve patients’ quality of life. Phase 4 : Moving forward the group aims to seek funding to extend this work into a research project and ultimately to drive further research through a dedicated research post.

Introduction The Gold Standard Frameworks (GSF) Committee devised Prognostic Indicator Guidance in November 2007 to ‘aid identification of adult patients with advanced disease, in the last months or year of life, who are in need of supportive or palliative care’. Methods This research used the GSF `surprise question9 to formulate a list of patients predicted to die within 1 year with end stage renal failure and to establish the specificity and sensitivity of this register. Results 58 patients were added to the list during the follow-up period of which 28 (48.3%) died during the same period giving an annual mortality of 32.2%. In comparison with the patients who died during the follow-up period but were not added to the at-risk register, those on the register had a much higher mortality rate (32.2% vs 7.8%). Identification of patients with chronic kidney disease and reduced life expectancy by this method appears to have a high sensitivity (66.7%) and specificity (77.9%). In particular, the negative predictive value for mortality for those on the at-risk register appears to be very high (88.3%), indicating the very low mortality among those not on the register. Conclusions Patients with chronic kidney disease and a reduced life expectancy can be accurately identified by a multi-disciplinary team using the surprise trigger question with a relatively high sensitivity and specificity. The accurate identification of patients with reduced life expectancy allows appropriate end of life care planning to begin in keeping with patients9 wishes and within published guidelines.