Case study:

11 May 2010

Supportive Care Pathway in Birmingham

Key points

The Pan Birmingham Cancer Network has developed a specially tailored end of life care pathway for all patients in acute hospitals, regardless of diagnosis.

The pathway, which is called the Supportive Care Pathway (SCP), is currently being used on seven wards across Sandwell and West Birmingham Hospital NHS Trust with 200 patients having been started on the pathway since January 2009. The trust is committed to extending its use to all its acute wards in due course.

The underlying principles of the SCP, which can be used in the last year of life, are diagnosing dying, regular holistic assessment, symptom control, rationalisation of medications and interventions, anticipatory prescribing, communication and bereavement care.

The aim is to identify dying patients promptly and improve the quality of end of life care by providing a focus on end of life issues and ensuring the multidisciplinary team is closely involved at every stage. The pathway is not prescriptive and does not curtail any care that would benefit the patient. However, because it is an end of life care pathway, it will direct the team to consider comfort measures as a priority.

The SCP sets out goals through a holistic assessment tool. Every day the team is prompted to consider rationalising interventions and medications through an individual patient-centred approach, so decisions are made either with the patient, or, if this is inappropriate, in their best interests.

Once the patient is on the pathway there are three possible outcomes. The team can decide the patient is no longer at the end of their life and the pathway can be stopped and regular documentation resumed. Alternatively, the patient can be discharged to home, hospice or nursing home. But most will stay on the pathway until they die.

The pathway also includes a section for staff to document discharge information and a last offices section which clearly documents the care that the bereaved and the patient receive after death.

Rolling out the SCP is a major task since the trust is spread over three sites and most staff have never used an integrated care pathway before and are not confident about managing end of life care patients. As a result the trust employed two facilitators to implement the pathway. Supporting documents, including symptom control algorithms and anticipatory medication prescribing guidelines, were also developed to help staff and standardise the quality of end of life care.

An intranet site has been set up to support staff. There is also a resource folder on each ward with up to date information about the palliative care team, symptom control, bereavement support and the pathway. A comprehensive training plan will ensure all staff have access to ongoing training in end of life care and the use of the pathway.

Critical success factors in embedding the SCP into practice include identifying key stakeholders and obtaining their support and using a positive change management strategy. This means all challenging of practice is done in a learning environment and there is regular feedback between facilitators and ward staff to ensure staff feel involved in the process.

Experience so far suggests the SCP has had a positive impact on patients at the end of life. Staff have been enthusiastic since the SCP gives them guidance and support and empowers them to deliver high quality end of life care.

The SCP team is also in the process of developing an SCP for critical care patients as well as a last days of life information leaflet for people who have a relative who is at end of life.