By Dr. Joseph Hawkins, Consultant in Palliative Medicine, Ashford and St Peter’s Clinical End of Life Lead, Ashford and St Peter’s NHS Foundation Trust. Twitter: @JoeHawk75825077

How do you identify the most unwell patients who aren’t already being identified- this is the question we have been asking ourselves.

Ashford and St Peter’s Hospital NHS Foundation Trust, a 500 bedded district general hospital, has decided to try something different for ‘reset week’. Each day a list of patients was generated for patients admitted to hospital with a history of 3 or more prior admissions in the past 6 months. This number of re admissions reflects the national picture of admissions before death; that patients in the last year of life will experience hospital admission in 90% of cases and that they have an average of 2.5 hospital admissions prior to death⁴. 3 admissions was therefore likely to represent a poor prognosis in these patients. We excluded obstetric and psychiatric patients and under 18 year olds.

Early review shows the following trends: In January and February 2022 the total number of patients appropriate for our input was 196. These numbers continue to be around 70% of the total of adults (280) on their 3^rd or more admission in the past 6 months. The percentage appropriate for Specialist palliative care team input was approximately 18% (35).

The commonest underlying diagnoses, in order or frequency, were: dementia, heart failure, COPD and cancer. The frequency of evidence of ACP having been undertaken with these patients was approximately 1:17. We used a number of tools to help highlight the recognition that these patients are unlikely to benefit from significant hospital led interventions including the SPICT tool and also the PPI^1.

Most importantly to us was that these patients were not being picked up as individuals for whom diminishing returns from acute hospital interventions were being experienced and for whom hospital stays were likely to cause as much risk of harm as potential benefit.

Not many of these patients identified in our ‘reset project’ required the specific input of a palliative care team -only 18% of those seen. This group demonstrated a universal need for some interaction with or possibility of interaction with palliative care services whilst recognising that this does not mean that all patients will require the same level of interaction. For some patients the intervention required by palliative care may be with the treating team in an acute setting, a recognition of goals eg: understanding PPC and clarity of communication around what can and what cannot be achieved with acute setting services and support in attaining these goals.

The Public Health England 2017 commissioned report on understanding the economics of palliative and end of life care³ shows a net benefit across a number of RCT’s internationally, including in the UK, of palliative care service provision and health economics. A key example of this for the purpose of illustration; was a two hospital run RCT in the USA⁴ that showed a clear benefit on palliative care hospital inpatient MDT services Vs a control group when looking at costs- saving: net £3567 per patient, re-admissions and ITU admissions (12 Vs 21), over 6 months, there were no differences in survival or symptom control between the two groups⁴. Funding more palliative care input can ultimately be justified financially in the NHS as well as being part of an ethically balanced medical approach when considering justice and principalism.

Our project has demonstrated significant need in the hospital population and also that much of this need can and should be delivered by non specialist palliative care services with the help of palliative care in identification and support through teaching and training.

Perhaps most importantly this shows what we’ve known for some time – palliative care isn’t a defined moment in a person’s illness trajectory it’s a part of their illness therapy, or to put it more figuratively: palliative care is not a cross roads but rather it is the map.

References:

1. https://blogs.bmj.com/spcare/2021/12/15/how-to-tell-if-your-patient-is-dying/
2. Murray CJ Abbafati C Abbas KM et al. Five insights from the global burden of disease study 2019. Lancet. 2020; 396: 1135-1159
3. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/guidance
4. Bekelman JE Halpern SD Blankart CR et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries JAMA. 2016; 315: 272-283
5. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/612377/health-economics-palliative-end-of-life-care.pdf#page72
6. Gade G, Venohr I, Conner D, McGrady K, Beane J, Richardson R H, Williams M P, Liberson M, Blum M, Della Penna R., 2008. Impact of an inpatient palliative care team: a randomized control trial. Journal of Palliative Medicine 11(2):180–190.