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Hospitals in England 'failing' dying patients, warns major audit

Hospitals are “falling short” on providing proper care to dying people in their final days and hours, a new review has found.

There are “significant” variations in care provided by hospitals across England, according to the National Care of the Dying Audit for Hospitals.

Around half of all deaths in England occur in hospital. But experts have said that major improvements are needed to ensure better care for terminally ill people. And more needs to be done to support patients’ families, carers and their friends.

“I am seriously concerned about the variations in care”

Norman Lamb

Many clinicians are failing to communicate properly with dying people or their loved ones and hospitals “do not recognise this as an important issue”, the authors said.

The audit, led by the Royal College of Physicians (RCP) and Marie Curie Palliative Care Institute Liverpool, concluded that all staff who care for dying patients need to be specifically trained in the care of dying patients - particularly in communication skills.

Researchers assessed the quality of care received by 6,500 people who died in 149 hospitals across England between 1-31 May last year. They also questioned 850 bereaved relatives and friends and assessed services available in each organisation.

For most patients, healthcare workers realised they were in their last days of life, but less than half of patients capable of discussion were informed of this.

It appeared that dying people were also left out of clinical discussions, for instance 17% of patients were told they were being assessed to see if they needed artificial hydration or nutrition. And one in five were asked about their spiritual needs.

Meanwhile, 24% of bereaved loved ones said they did not feel as though they were involved in decisions about care or treatment.

Some 37% reported that the overall level of emotional support given to them by the healthcare team was fair or poor.

And a quarter said they did not feel adequately supported during the last two days of their loved ones’ life.

When the researchers assessed the hospitals, they found that mandatory training in care of the dying was only required for doctors in 19% of hospital trusts and for nurses in 28%.

“Communication with patients and their families is generally poor”

Kevin Stewart

The authors made a series of recommendations to improve the care of dying patients.

They said hospitals should provide a face-to-face specialist palliative care service from at least 9am to 5pm, seven days a week, and decisions about care of dying patients should be made by multidisciplinary medical teams and discussed with the patient or their family where appropriate.

All hospitals should undertake a local audit of their care of dying patients and they should have a designated board member responsible for palliative care.

Dr Kevin Stewart, chair of the audit’s steering group and clinical director of the RCP’s clinical effectiveness and evaluation unit, said: “Although some aspects of care are good in hospitals in England, I am deeply concerned that some hospitals are falling short of the excellent care that should be provided to both dying people and those important to them.

“In particular, communication with patients and their families is generally poor,” he said.

“It is disappointing that hospitals don’t seem to recognise this as an important issue, not just for those experiencing this in their own lives, but for the wider public,” he added.

“Everyone wants to know that if they are in the same situation, their needs and those of their families, friends and those important to them will be met, with clinically appropriate treatment, sensitivity and compassion.”

“There’s only one chance to get people’s care at the end of their lives right”

Jane Collins

Professor John Ellershaw, director of the Marie Curie Palliative Care Institute at the University of Liverpool, said: “It is unacceptable in the current day and age that hospitals are failing patients, and their families, in the care they receive at the end of their life.

“Too many patients are dying badly in our hospitals when we know how to care for them well,” she said. “If some hospitals can provide good outcomes in care then all hospitals can.

University of Liverpool

John Ellershaw

“This audit provides a clear challenge to those hospitals that are failing to provide best care for dying people to look at why they are failing and improve.”

Dr Jane Collins, chief executive of Marie Curie, which funded the research alongside Public Health England, said: “There’s only one chance to get people’s care at the end of their lives right but we know that our hospitals do not always provide the high quality care and dignified death that we all have the right to expect.

“The recommendations of the audit are clear. In particular, more needs to be done to improve governance, staff training, access to pastoral and specialist palliative care teams.

“We need everyone involved to take decisive action to ensure dying people and those close to them get the care and support they need and deserve.”

Care and support minister Norman Lamb added: “All patients should be receiving high quality and compassionate care in their last days of life - there can be no excuse for anything less.

Norman Lamb

Norman Lamb

“This report shows evidence of very good care but I am seriously concerned about the variations in care, and improvements are needed in the way some clinicians communicate with patients and support families,” he said.

“I am determined this should improve,” he said. “To help address these issues, we are working on plans to support all services in giving everyone in the last days and hours of life, and their families, the good quality, compassionate care they deserve.”

Readers' comments (12)

  • 'Many clinicians are failing to communicate properly with dying people or their loved ones and hospitals “do not recognise this as an important issue”, the authors said.'

    'For most patients, healthcare workers realised they were in their last days of life, but less than half of patients capable of discussion were informed of this.'

    http://www.bmj.com/content/347/bmj.f4085/rr/652862





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  • This happened in my late wifes case as we were never told she was dying and she was put on the pathway without our knowledge or any discussions with us. We did not know they had put her on the pathway until about 3 months after she died when I got her medical records. This was in 2013.
    they also falsified hospital records and a review was done which pointed out many points where the hospital had failed yet amazingly the reviewer (who works for the hospital)concluded she could find no negligence. They withdrew food, water and medication claiming she was too drowsy, too sleepy and too poorly to eat. All this happened at Blackburn Royal Hospitals who I must add that they are still under special measures.

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  • Sadly, the withdrawal of the Liverpool care pathway that gave clear guidelines to all clinicians as to how to communicate with patients, relatives and community and was holistic in all aspects of spiritual and symptom control may have contributed to this. There is now a distinct lack of guidance for ward staff. Who suffer, the patients and relatives?

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  • Compassionate and competent nursing care of the terminally ill patient is something everyone, patients and relatives, have the right to expect and receive. As to whether any nurse should feel that she is duty bound to inform a patient that he/she is dying is entirely another matter. In my experience not all patients wish to be told and thrusting this information upon them might not enhance their final moments.

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  • michael stone

    In the foreword to the report, Dr Jane Collins tells us:

    ‘We only have one chance to get end of life care right and sadly sometimes we don’t. There are few surprises in the National care of the dying audit for hospitals (NCDAH) England report. It reflects many of the issues identified by the Neuberger Review, as well as what needs to be done to improve the quality of hospital care for dying people and their families.


    For the first time the report includes the views of over 800 bereaved carers. This provides further insights into relatives’ own views about how well hospital staff respond to the physical, emotional and spiritual needs of people in their final days of life, their families, carers and those close to them.’

    This is, I think, the 3rd or 4th ‘version’ of this audit, and it is interesting that only now has it looked at input from bereaved carers.

    There was also another recent survey (for the Dying Matters Coalition) which was reported on page 19 of The Times on May 12th, and that report said the survey found that:

    ‘A Quarter of GPs have never initiated a conversation about death with someone they are treating, even though on average 20 of their patients will die each year.’

    Francis, Neuberger, the NCEPOD ‘Time to Intervene?’ report, have all pointed out that there are major issues (legal, logical and wider) about communication when patients are end-of-life (there is also an issue about post-mortem behaviour for death at home, which I explained in my link below): those are quite distinct from purely ‘clinical’ issues, and clinicians seem much worse at coping with these wider issues [than at dealing with purely clinical issues].

    http://www.bmj.com/content/347/bmj.f4085/rr/654490

    Anonymous | 15-May-2014 1:31 pm

    The Neuberger review was about the LCP, and it found this 'non communication' was a serious problem, whatever the LCP Guidance actually stated. And the Mental Capacity Act, and also the legal principle of patient autonomy and the requirement to obtain informed consent for medical interventions, have not been 'withdrawn' - there is absolutely no [legal] justification, for this non-communication, when it is prevalent.


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  • Nurse Education in particular needs to address this urgently.
    Pre reg and CPD required via work appraisal.

    The way we organised and practice our whole care system is atricious. It is dying too.

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  • I have been involved with QELCA Quality End of Life Care for All , in my trust in North Somerset. A trained nurse from each ward experienced work in the local hospice and with the community nurses . We then went back to our areas to educate our own staff , and had an ongoing educational plan in place . We were given allocated study days every week , 6 hours which was vital .There is also work to promote , in the community Advance care planning. I think it has greatly improved patient care where I work .

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  • we did the best one possibly can on a general ward given the work load and restrictions on our time but still managed to offer a high standard of care and support the patients' relatives. we never heard any complaints from relatives and unless death was sudden and unexpected, and even then, we normally managed to give them a single room.

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  • michael stone

    I briefly glanced over bits of this report yesterday - it isn't exactly 'problem free'.

    Not only did it not include any feedback from bereaved relatives who are formally complaining (which makes the rigour of its 'the behaviour was unsatisfactory' end very doubtful), but it uses some wording in its summary report that is simply wrong: as I pointed out to the RCP this morning in an e-mail -

    'The decision that the patient is in the last hours or days of life should be made by the multidisciplinary team and documented by the senior doctor responsible for the patient’s care.'

    That ISN'T 'a decision'. This is important – expert clinical opinions (in other words, prognoses) are a factor considered along with non-clinical issues, during decision-making: muddling ‘decision’ and ‘opinion’ in this way, is entirely unhelpful.

    The time of an execution is a decision – the [predicted] time of a future natural death is an opinion (the accuracy depends on expertise, but it is an opinion).

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  • I work in the private health sector and have confidently used the Liverpool Care Pathway,I feel we got the care right for each individual. W e communicated with the person and their loved ones and were transparent with their care.When the person had passed away,we were able to give the family time to express their feelings. I would like to say that private care sector receives negative press when in fact they can give peron centred end of life care.

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  • It amazed me to read a man's account of failures, re his wife's death, on the LCP and minutes later an anonymous writer states that it is since the pathway was withdrawn that care has deteriorate. Wake up nurses, the pathway was cruel in denying fluids etc and relied on sedation to mask symptoms and bring about unconsciousness, thereby hastening death. We must be there for patients and relatives, at this sad and final time of life.It's not rocket science to realise that communication is very important. In my view, patients are better off and better cared for in their own homes wherefamily are included in a positve way, esp in the communication and empathetic approach

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  • My mother died recently in a nursing home, She was frightened and in pain until sedation and analgesia levels were increased to give her comfort. It was a fight to get the staff to do this. More guidance is needed.

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