PALLIATIVE CARE Ticking the Boxes
Cognisco CEO, Mary Clarke explains why caring for the dying requires more extensive guidelines.
In July this year, NHS England’s health watchdog the National Institute for Health and Care Excellence (NICE) put forward new draft guidance for caring for the dying.
Consultation on the guidelines finished in September and it’s expected the full recommended guidelines will be published in December. The guidelines are designed to be an alternative to the controversial Liverpool Pathway that was developed during the 1990’s and phased out in 2014.
The aim of the Pathway was to ensure people had a dignified and comfortable death, and offered a checklist to ensure patients were free from invasive procedures and medications that they no longer required.
However, it has been criticised for being a “tick-box exercise” that left some patients vulnerable. An independent government review published this year found that some patients were left thirsty, without food and treatment and some were being looked after by inexperienced staff. According to reports, whilst the Liverpool Pathway itself was sound, some staff may not have been following its recommendations correctly.
NICE’s guidelines take a more patient- centred approach, focusing on the importance of staff recognising when a person is nearing the end of their life and recommending information that should be gathered at this time, including clinical signs and symptoms, the person’s medical history and their wishes. According to NICE, the assessment of patients clinical state should be made on a team basis, not just by one individual, and should be reviewed every 24 hours.
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To improve palliative care, Trusts will need to be confident that these guidelines can be followed and applied by every member of staff in every situation and for this to happen, a new approach to training and assessment is needed.
Staff carrying out the patient assessments will not only need to be competent and trained, they will need to be able to apply their knowledge and training correctly in every situation to ensure the best level of care is provided for patients in the final days of their life.
One of the common problems facing the NHS is that too often training is of a ‘one size fits all’ nature and not tailored to the specific needs of members of staff. The training is untargeted and not guaranteed to address knowledge gaps which could place patients at risk.
Another more effective approach would be to introduce situational judgements assessments that correlate competence and confidence levels and measure how people think, behave and act in every aspect of their jobs. These kinds of assessments highlight risk factors, for example if someone is highly knowledgeable but not confident they might make the wrong decision under pressure or worse, if someone is confident but incompetent, they may put their patients at great risk.
This approach to identifying and measuring risk has already been adopted by one NHS Trust maternity unit, where improving health and safety practices was high on the agenda. The Unit had experienced a rise in the number of cases of women suffering from postpartum haemorrhage.
recognising when a person is nearing the end of their life and recommending
“NICE’s guidelines take a more patient-centred approach, focusing on the importance of staff
information that should be gathered at this time.”
Analysis of such incidents highlighted the need for staff to be able to anticipate, recognise and respond immediately to women at risk of rapid clinical deterioration in order to improve patient safety and reduce the likelihood of major obstetric haemorrhage.
A specialist online assessment tool was developed to evaluate midwives and doctors in simulated acute clinical situations. The assessment evaluated factors including people’s communication skills and decision making, their ability to spot risks, the handover to other colleagues and how they would escalate a situation, amongst other factors.
Since the introduction of these assessments the Trust has seen a measurable decline in patient safety incidents.
Improving palliative care is essential, but it’s only by identifying and mitigating their people risks that the NHS will truly be able to do this; guidelines and processes alone will not be sufficient.
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