Background NICE quality markers for COPD state that all patients with end stage COPD should have access to specialist palliative care support. To improve identification and management of patients with end stage COPD in North East Hampshire, an integrated multidisciplinary team (MDT) was established between the local hospice, hospital and community teams. This evaluation reviewed the activity of the MDT after 1 year.
Method The list of patients discussed at each meeting (June 2012 – June 2013) was reviewed and cross referenced with the patient's electronic patient record to determine whether they were referred to the hospice. For patients who were known to the hospice, outcomes including ongoing specialist palliative care input, discharge and place of death were recorded.
Results 34 patients were discussed over 4 meetings. 24 (71%) were already known or referred to the hospice during the year. The majority (74%) had a diagnosis of COPD. 12 (35%) patients died over the year with 58% dying at home or in the hospice. 15 (44%) patients had ongoing specialist palliative care needs requiring input from the hospice MDT as well as the community matron. 2 patients were discharged to the care of the community matron.
Conclusions A community respiratory MDT meeting provides an important forum for discussion of patients with end stage disease. The meeting facilitates information sharing and coordination of care between the key health professionals involved in the patients management. Although the majority of patients were reviewed by the specialist palliative care team, community matrons remained integral to patient care. As the MDT develops, it will be important to ensure that patients who wish to die at home or in the hospice are identified and supported to meet their wishes. This may result in a reduction in the number of patients dying in the acute hospital environment.
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