Case study:

11 November 2008

Decisions at Life’s End Project (DALE) in Leicestershire and Rutland counties

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Key points

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The DALE (Decisions at Life’s End) service has been providing care and support for people in Leicestershire and Rutland counties at the end of their lives since May 2007.

The project, a two-year Partnerships for Older People Project (POPP), funds extra staff and facilities in existing services and helps to integrate those services in the community, enabling end of life care to be seamless, comprehensive and fully co-ordinated.

A measure of the project’s impact in care homes is that there is much greater partnership working between homes and palliative care services.Care home staff say they feel more confident in supporting those who are dying and more residents are able to stay at home rather than be admitted to hospital. It is now possible to discharge a resident from hospital within four hours to allow them to die in their place of choice– previously this would have been impossible.

The project funds a community staff nurse in each community nursing team (11 whole time equivalents), 22 Marie Curie health care assistants, an Age Concern befriending service, a rapid response equipment service and a handy person. Its operational service has also been able to support care homes, via the local community nursing team, by providing additional staffing, equipment and specialised support.

The DALE pathway begins with the Gold Standards Framework (GSF) and in collaboration with LOROS (the Leicestershire and Rutland Organisation for the Relief of Suffering) the project funds a GSF facilitator in the counties care homes. This enables staff to identify those requiring palliative care, assess their needs and then plan the appropriate care.

One of the most striking consequences of introducing GSF has been staff realisation that pro-active planning of care with residents, family, GPs and nurses will result in a dying resident staying safely at home, even if there is a crisis, because symptoms can be controlled.

Relationships with local GP surgeries have also improved. Before GSF care home staff often felt their opinions and requests for dying residents were not always acknowledged by the GP. As soon as a care home implements GSF, managers contact the practice residents are registered with and ask how the care home can work alongside each practice in maintaining their GSF register. Many managers from the care homes have met their GPs to discuss a joint approach.

One benefit of the GSF advanced care planning is that vital documentation is completed pre-emptively. A comprehensive out-of-hours form provides written, authorised information from the GP to the out-of-hours services giving details of the end of life care required by the resident. In addition each resident’s care will be fully discussed by a multidisciplinary team and this informs and supports the care plan.

In collaboration with LOROS the DALE project also funds two facilitators who provide training and support in using the Liverpool Care Pathway (LCP) to care homes and community nursing teams across Leicestershire County and Rutland PCT. Nurses report that GPs are now far more prepared to prescribe pre-emptive drugs. As a result all the drugs a resident might need are made available as soon as they are put on the LCP. This in turn reduces the need for out of hours medical support from a doctor who may not know the resident and may not be confident in prescribing controlled drugs.

Through the support of community nurses and LCP trainers nursing homes have also learnt more about symptom control and the need for pre-emptive prescriptions. As a result trained nurses within the homes are now making greater use of syringe drivers in their palliative care.

The DALE project nurses continue to support care homes in implementing the GSF and LCP after initial training. Locality support meetings for care home managers and staff are held on a three-monthly basis. In addition out-of-hours GP deputising services are receiving palliative and end of life training.

Community nursing teams take referrals and act as the care co-ordinator and case manager throughout the DALE pathway. This provides essential continuity from the wide range of services each dying person requires.

Evaluation also shows that the palliative care needs of the elderly mentally infirm, particularly managing pain and other symptoms, are now being considered where previously they were often overlooked. The pilot also funds training and advice on end of life care and mental capacity training to care homes looking after elderly people with learning difficulties and mental health problems.

The evaluation suggests that good palliative care not only pays its way by cutting hospital admissions and reducing bed days but also raises quality of care at the end of life.

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