Introduction This 18 month project aimed to enhance the opportunities for patients with end-stage heart failure (HF) and their families to benefit from hospice and specialist palliative care services (SPCS) to facilitate them to plan for, and experience better end of life care.
Method A project team comprising representatives from the HF service, care of older people, primary care, hospital palliative care, patients and families and hospice representatives worked alongside a project lead to design a model of care and pathway for people with end stage HF. A new Supportive and Palliative Care in Heart Failure MDT was established, providing an interdisciplinary forum for identification of those at end of life, and aiding referral to SPCS. A patient information leaflet was designed and printed. Education was delivered to the HF team on palliative care principles, and to the SPCS on management of end stage HF.
Results There is now an established pathway for care of these patients which has improved understanding and communication between the HF and specialist palliative care teams. The MDT meeting is held twice monthly and HF referrals to specialist palliative care have more than doubled (96 patients). A documentation audit of advance care plan (ACP) discussions demonstrates that 64% patients reviewed at MDT had discussions about their wishes. However, less than half of the patients had entries on the Electronic Palliative Care Coordination System (EPaCCS) with only 6% having documentation of ACP discussions.
Conclusions Feedback such as ‘All care and treatment have been excellent’. (Patient) and ‘Much better links between heart failure team and palliative care team with great benefits for patients’ (Staff) indicate that this collaborative project has been a positive experience, enabling more patients and families to access hospice and SPCS in their locality. Further work is required to increase use of EPaCCS and sharing of ACP discussions.
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