This year, the National Confidential Enquiry into Patient Outcomes and Death, covered a whole range of issues, but has a chapter (8) on end of life care for people who died soon after admission to general hospitals. The report is a well-written analysis of questionnaires completed by the original team and assessments by expert advisers. There are some interesting case studies.

The picture is not good as the recommendations of this chapter, reprinted below, show; a third did not receive good practice. The good intentions of the end-of-life care strategy are compared with the actuality. You could sum up the main issues as a failure to plan for the care of people who were clearly coming towards the end of life, and to engage with the patient and relatives about the care plan (if any – often there wasn’t). The picture of no decisions about ‘do not attempt resuscitation’ orders not being made, or being made by junior doctors, and often not being discussed with patients and families, is contrary to professional guidance and a sad indictment of the failure in many hospitals to take responsibility for care for people who are dying.  They also did not involve the palliative care team of the hospital when they should.

49.8% of patients, who died with 96 hours of admission to acute hospitals, were not expected to survive and 68.7% of these were considered to have received good practice.

The advisors considered that 5.9% of patients had an unnecessary admission to hospital and this was due to a deficiency of social and medical support in the community.

In 16.9% (219/1293) of patients who were not expected to survive on admission there was no evidence of any discussion between the health care team and either the patient or relatives on treatment limitation.

Of those patients not expected to survive on admission in only a third were end of life care pathways used and 30% did not have do not attempt resuscitation (DNAR) orders.

In 21.8% of cases DNAR orders were signed by very junior trainee doctors.

Palliative care teams were rarely involved in the care of patients who died in this study.
There were examples of where health care professionals were judged not to have the skills required to care for patients nearing the end of their lives. This was particularly so in relation to a lack of the abilities to identify patients approaching the end of life, inadequate implementation of end of life care and the poor communication with patients, relatives and other health care professions.

National Confidential Enquiry into Patient Outcome and Death (2009) Caring to the End? A review of the care of patients who died in hospital within four days of admission. London: NCEPOD

On the web: http://www.ncepod.org.uk/2009report2/Downloads/DAH_report.pdf