End of life care in nursing homes:
Understanding and mapping solutions
Many care homes feel isolated and do not have the support they need to provide top quality end of life care. The National End of Life Care Programme recently commissioned a study to examine how these issues affected the care of older people in nursing homes. The study was conducted by staff from the Sue Ryder Care Centre for Palliative and End of Life Studies at the University of Nottingham and from the International Observatory on End of Life Care at Lancaster University between September 2007 and November 2008.
The study looked at the drivers and barriers to good quality end of life care for older adults in nursing homes through an in-depth study of two nursing homes in northern England and a survey of surrounding nursing homes in the areas.
It found many examples of good practice in end of life care, especially among those nursing homes that were implementing end of life care tools such as the Liverpool Care Pathway (LCP) and the Gold Standards Framework (GSF) and It also identified a number of areas that needed improvement.
Some of the main themes to emerge were:
- The importance of leadership: Commitment from senior staff (owners and managers) is vital.
- Inequalities of care: An 'inverse care law' appeared to operate where those homes that were not implementing end of life care tools had less access to support and became more isolated
- Variability in access to key staff: In end of life care nursing homes rely on the expertise of GPs and some also want more help from district nurses but the level of support received is very uneven.
- Variability in access to information, funding, equipment, resources and training: This includes poor information about residents being discharged from hospitals, patchy out of hours support, insufficient help with equipment and limited access to training
- Importance of facilitators to end of life care: Most nursing homes have a clear vision about key priorities for improving end of life care. Help from key personnel in local health and social care communities are critical in achieving these. Implementing the end of life care tools is an important related factor.
- Commissioning: It is crucial PCTs take an active role in building capacity, particularly in weaker or failing nursing homes. Nursing and residential homes must be seen as integral to the wider strategy of improved end of life care for older people.
The study produced 13 recommendations:
For care homes and staff:
- Consider setting up local networks to encourage practice development
- Bear in mind that NHS Continuing Healthcare funded care is available for end of life care and can be delivered in care homes
- Be aware of the National End of Life Care Strategy and the responsibility of local authorities and PCTs to provide ongoing support
- Implementing end of life care tools such as the GSF and LCP can improve practice and help bring in external support
- Consider strategies to develop leadership, including designating some homes good practice 'beacons'
For SHAs, PCTs and local authorities:
- Commissioning needs to ensure proper levels of nursing, medical and equipment support to care homes, particularly in relation to out of hours practice and availability and maintenance of syringe drivers
- Consider how to involve nursing home representatives in your end of life care strategy
- Ensure residents receive consistent and coordinated medical care from a GP familiar with their needs
- All homes should be able to access outside support regardless of whether they are implementing end of life care tools
- Many deaths in care homes are not from cancer and a growing proportion of residents have dementia. The community matron can play a vital role in addressing the management of people with long-term conditions
- The provision and accessibility of training for care home staff needs to be examined urgently
For acute hospitals:
- Consider how information is provided to care homes about residents discharged from hospital
- Think about monitoring admissions of residents from care homes in the last days of life as well as auditing the reasons for admissions and informing PCTs and SHA end of life care working groups.