Case study:

17 August 2007

Implementation and maintenance of Last Days of Life Pathway in Nottingham University Hospitals Trust

Key points

Nottingham University Hospitals Trust has implemented the Last Days of Life Pathway in both its acute hospitals as a means of empowering staff and raising standards and quality in all aspects of end of life care.

The pathway (based on Liverpool Integrated Care Pathway for Dying Patients) is now being used in 30-60% of all deaths, which suggests the foundations are laid but there is still much work to be done to ensure it becomes a routine part of care of dying patients.

Audit of completed pathways has indicated improved, more consistent end of life prescribing (following guidance for symptom control), better record-keeping and greater scrutiny of the need for medical and nursing observations and procedures.

The trust has a pathway facilitator covering both sites and staff are benefiting from a rolling programme of education.

One of the big challenges has been introducing these innovations during a difficult period of change for the trust.

Funding for the facilitator post has come from a variety of sources over the last five years and is currently met by Nottingham University Hospital’s specialist palliative care unit charitable trust fund.

This presents problems in maintaining and developing the pathway. The challenges are being addressed by identifying champions on hospital wards, supporting staff as much possible and making full use of the palliative link nurse network.

Some staff still have anxieties about using the pathway.

In particular some have difficulties diagnosing dying or recognising the dying process.

They also feel anxious about discussing dying, death and bereavement with patients and relatives and feel ill- equipped to give psychosocial and spiritual care to dying patients.

The trust’s future plans include introducing a more specialised pathway in critical care settings, auditing key staff groups about their perceptions of the pathway and raising awareness of the pathway with patient groups.

It also hopes to develop a website and web-based education.