Aim to improve care of patients identified in their last year of life by increasing the number of patients identified in their last year of life; recording patients' Preferred Place of Death (PPoD); improving transfer and documentation of advance care planning decisions between primary and secondary care, and reducing inappropriate readmissions and length of stay at the end of life.

Method Piloted on two acute medical wards, four workstreams were established to plan, implement and evaluate the project. Using a marginal gains approach, where multiple small changes produce a significant result, the team have: implemented the AMBER care bundle and linked with the Locality End of Life Register; established an End of Life Information Hub to facilitate sharing of information across boundaries; delivered an education package including multiprofessional communication skills training, role modelling on ward rounds and e-learning; improved facilities for carers of dying patients, including the provision of recliner chairs and Bradford Bags containing items to make relatives' stay more comfortable.

Results 179 patients have been entered on the End of Life Register. Of these, recording of Preferred Place of Death has increased from 4% to 88%, with 64% of those who died achieving their preference. There has been a significant reduction in number of admissions, length of stay and occupied bed days for patients in their last year of life. The speed of fast-track discharges has improved from 60% within 48 hours to 80%. An increased number of advance care planning discussions are taking place and feedback from staff at 3 months shows a sustained increase in confidence in having end-of-life conversations.

Conclusion Although numbers are small, initial evidence demonstrates a positive impact on care for patients in their last year of life. Roll out of the project and sustainability remain challenging.