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Development of an integrated model for earlier identification and provision of palliative care for patients of all diagnoses
  1. Charles Daniels1,
  2. Mark Dancy2,
  3. Temo Donovan3,
  4. Audrey Alimo3,
  5. David Smith4 and
  6. Lauren Berry5
  1. 1St Luke's Hospice, Harrow, UK
  2. 2Northwest London Hospitals trust, Brent, UK
  3. 3West London Cardiac Network, London, UK
  4. 4Brent PCT, London, UK
  5. 5St Luke's Hospice, Harrow, UK


Introduction The National EOLC Strategy seeks to improve access to high quality palliation for patients of all diagnoses. One such group for which this is difficult is advanced heart failure.

Aim To use auspices of NHS Improvement to develop cross organisational integrated pathway for advanced heart failure (HF) to ensure better end of life care (EOL).

Results A. Retrospective audit identified 26 deceased patients known to the heart failure nurses. The majority had no EOL discussions or specialist palliative care and died in hospital. Most had multiple admissions with average length of stay of 31 days in last year of life.

B. Key stakeholders were brought together to develop a new pathway and tools which facilitated patient choice, addressed symptom management and anticipatory care planning.

C. Tools include

  • Tools for HF nurses

  • Patient and Carer assessment tool

  • ‘Trigger Tool’ to identify patients who are a ‘cause for concern’. Creates gateway for appropriate joint management between cardiology and SPC services.

  • Aide memoire for action following identification of patients

  • Home management folder.

D. Key features of pathway

  • Monthly advanced heart failure forum. Enables hospital /community heart failure nurses to discuss patients identified as ‘cause for concern’ with cardiologists and agree CLEAR action plan. Palliative care input to forum is planned

  • Bi-monthly meetings between palliative care nurses and community HF nurses

  • Joint Heart Failure clinic.

E. Re-audit revealed

  • Increased use of specialist palliative care services, for example, homecare, day care, hospice and hospice at home

  • Increased EoL discussions with HF nurses

  • Increase in documented preferred place of care and achievement of death in PPC

  • Reduced hospital deaths.

Conclusion Cross organisational work can develop shared pathways, tools and training which improve care for end stage HF and improve skills of HF nurses.

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