Audit finds failings in hospital care for dying

A MAJOR audit of care provision for patients dying in hospital has found significant variations across England and deficiencies in communication and the availability of palliative services.

Around half of all deaths in England happen in hospitals and the audit assessed the quality of care received directly by 6,580 people who died in 149 hospitals between 1 May and 31 May 2013. The audit also incorporated the results from questionnaires completed by 858 bereaved relatives or friends.

The audit found that healthcare professionals recognised most patients who were in the last days of life (87 per cent) but told less than half of these patients (46 per cent) capable of discussing their prognosis. Communication was better with family and friends of the patient, occurring in 93 per cent of the cases and on average 31 hours before death.

Most patients (63-81 per cent) had medication prescribed ‘as required’ for the five key symptoms often experienced near the end of life – pain, agitation, noisy breathing, difficulty in breathing (shortness of breath or dyspnoea), and nausea and vomiting – and a proportion were clinically assessed to see if they needed artificial hydration (59 per cent) and artificial nutrition (45 per cent) but discussions with the patient were only recorded in 17 per cent of those capable of having the conversation.

Only 21 per cent of sites in the audit had access to face-to-face palliative care services seven days per week, despite a longstanding national recommendation that this be provided; most (73 per cent) provided face-to-face services on weekdays only. The audit also found that mandatory training in the care of the dying was only required for doctors in 19 per cent of Trusts and for nurses in 28 per cent.

Among bereaved relatives, 63 per cent reported that the overall level of emotional support given to them by the healthcare team was good or excellent but 37 per cent thought it only fair or poor. Most relatives (76 per cent) reported being very or fairly involved in decisions about care and treatment of their family member but 24 per cent did not feel they were involved in decisions at all.

The National Care of the Dying Audit for Hospitals was led by the Royal College of Physicians (RCP) in collaboration with the Marie Curie Palliative Care Institute Liverpool (MCPCIL), and funded by Marie Curie Cancer Care and Public Health England.

The report makes 10 key recommendations aimed at driving up the quality of care for dying people across all Trusts, including face-to-face specialist palliative care service from at least 9am to 5 pm, seven days per week, and mandatory training in the care of the dying for all relevant staff. This should include communication skills training and skills for supporting families and those close to dying patients. Pain control and other symptoms in dying patients should be assessed at least four hourly and all interventions should be discussed with the patient and family/friends as appropriate.

Dr Kevin Stewart, chair of the Audit Steering Group and clinical director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU) said: "Although some aspects of care are good in hospitals in England, I am deeply concerned that some hospitals are falling short of the excellent care that should be provided to both dying people and those important to them. In particular, communication with patients and their families is generally poor.

"It is disappointing that hospitals don't seem to recognise this as an important issue, not just for those experiencing this in their own lives, but for the wider public. Everyone wants to know that if they are in the same situation, their needs and those of their families, friends and those important to them will be met, with clinically appropriate treatment, sensitivity and compassion."