Background Advanced care planning (ACP), communication surrounding dying, use of end of life (EOL) care pathways and achievement of preferred place of care (PPC) and death (PPD) are key components of quality EOL care. A baseline audit of current practice across 3 London acute hospital sites was carried out in 2010.
Methods Retrospective case note audit of 163 consecutive adult patient deaths (excluding dead on arrival). Data extracted and analysed using Microsoft excel.
Results Mean age 73.8 years (22–99), mean admission 19.2 days (0 – 120). Commonest reason for admission was sepsis 45 (28%), however 79 (48%) of patients had more than one significant underlying medical condition 34 (21%) had >2. 53 (33%) had underlying malignancy. 143 (88%) had DNAR orders, 1 patient had an advanced decision to refuse treatment. Ceiling of intervention documented in 94 (58%). 72 (45%) had no documentation of communication with carers, of these 51 (70%) had DNAR orders. 39 (24%) deaths were on the LCP, mean length of time on LCP 48 h (0–11 days). PPC recorded in 25, 22 as part of LCP documentation. When on the LCP, PPC hospital 13 (52%), home 7 (28%), PPD Hospital 11 (44%) Home 3 (12%).
Discussion Despite limitations of retrospective case note studies this audit is important. Doctors are recognising dying in most patients; signing DNAR and documenting ceiling of intervention. There is evidence of room for improvement in relation to ACP and communication documentation. PPC and PPD was recorded in 15% patients, most on the LCP, representing the dying phase of illness. The PPC data documented differs considerably from national figures PPC hospital 12% home 58%. This may reflect sample size but could represent a change of preference in PPC or PPD in very ill patients or reflect conversations being left too late in patients already on the LCP. It is an important finding needing replication and further investigation.
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