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MPs call for better training to improve nurses’ end of life care skills

  • 20 Comments

Nurses and other clinicians must receive tailored training to address the lack of confidence and skills they have in raising end of life issues with patients, a report by the Commons’ health select committee has said.

The MPs’ inquiry into end of life care found variation in the quality and practice of care given to people approaching the end of life – defined by the committee as those who appear likely to die within the next 12 months – within both hospital and community settings.

End of life care is unlikely to improve unless staff feel able to identify people who are close to dying and start conversations with them about where and how they would like to be cared for, said the MPs in their report.

“[Patient and family] experience will be made worse if they encounter poor communication and planning or inadequate professional expertise”

Sarah Wollaston

Evidence submitted to the committee by the Parliamentary and Health Service Ombudsman stated that half of all its complaints around this type of care featured poor communication – including between clinicians and patients or the family, within clinical teams and between hospitals and community services.

“Our case work has highlighted instances where people have only learned of their diagnosis through reading discharge summary information, and… In other cases, relatives have learned of bad news over the telephone from GP practice managers,” stated the Ombudsman.

The select committee has called for NHS England to work with care providers to roll out tailored training for all health and social care staff – including those in generalist, qualified or unqualified roles – who are likely to provide end of life care, which should include communication skills.

Meanwhile, clinicians must also receive training in advance care planning, especially around patients’ legal rights when making decisions about care, said the committee.

“We recommend Health Education England and NHS England set out how they plan to address the shortfalls in the staffing of community care services”

Health Select Committee

Evidence submitted to the inquiry suggests the Mental Capacity Act 2005 – the legislation which allows people to express their preferences for care and treatment in case they lack the capacity to do so in the future – is “not well understood”.

It also noted that a shortfall in community nurses and specialist outreach palliative care was providing a barrier to more people being able to die at home, which was often their preference.

“We recommend [national workforce planning body] Health Education England and NHS England set out how they plan to address the shortfalls in the staffing of community care services…This should involve their plans for the recruitment and training of district nurses,” the committee’s report stated.

Sarah Wollaston

Sarah Wollaston

As part of its 25 recommendations, the MPs also stressed that every provider should have a model in place based on the Five Priorities for Care – the guidance for workers when it is thought a patient will die in the next few days or hours.

Last year, the Five Priorities for Care replaced the controversial Liverpool Care Pathway, which had attracted negative media attention following reports that people were placed on the pathway without consent or the knowledge of friends and family.

Committee chair Dr Sarah Wollaston said: “The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers. At the most difficult of times, their experience will be made worse if they encounter poor communication and planning or inadequate professional expertise.”

Charity Marie Curie welcomed the report, adding the future government must make a “dramatic improvement” in access to high quality care in the community.

“[This should be] available for people early on in their illnesses so that they can live well and stay out of hospital for as long as possible,” said its chief executive Dr Jane Collins.

 

  • 20 Comments

Readers' comments (20)

  • michael stone

    I'm only about half-way through the report - but I must say 'Well spotted, sir !' to Martin McShane:

    79. Dr McShane, giving evidence for NHS England, commented on the confusion that exists around advance care planning: “I must admit that I have been trying to work out the lexicon around this and I am not sure it is entirely helpful: an advance care plan could lead to an advance statement and an advance decision to refuse treatment, and I think we are confused.”

    And re:

    'Evidence submitted to the inquiry suggests the Mental Capacity Act 2005 – the legislation which allows people to express their preferences for care and treatment in case they lack the capacity to do so in the future – is “not well understood”.'

    that in itself is a misleading representation of the MCA: the Act allows patients while mentally capable to express their decisions, and if a patient isn't mentally capable and has not clearly expressed a decision in advance, the Act requires that anybody making a best interests decision 'tries to work out indirectly, the decision the now-incapable patient would have made [had he still been capable]'.

    But while capable, patients would be well-advised to express their decisions - expressing 'preferences' leaves far to much room for subsequent 'interpretation' by other people, and too much room for 'challenge'.

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  • All the while we avoid saying these words ,Death,Dead,Died we will always be on the back foot with this.Why are we offering CPR as a option to an elderly ill person when we all know (including them ) that it's not going to work.Why do we seem fixated in preventing the elderly from dying,why have we designed a new title for dying ( end of life care ) We should not make dying more complicated than it already is ! but we are.

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  • it is not so much the lack of training and the necessary expertise but the time to exercise it where nursing falls short.

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  • Training and educating students in the basic skills and techniques of Nursing is, an academic process. Teaching them to 'Care' for people is much more complicate. As caring for people, in whatever state of physical or mental condition is an innate quality. You've got, or you haven't.
    Time and time again, highly trained 'nurses' have been churned out from colleges and universities, no doubt. However, when it comes down to the 'caring' bit, you are in a different area altogether.
    There are many caring nurses in the wards and working in the community, but, with limited 'resources', they cannot provide the care which needed by the patients.
    Others, however, may have the resources, but fail to use them, due to lack of caring. So patients will always be at risk at the hands of negligent, unscrupulous healthcare providers.
    Whilst I gladly approve of the conception the above report, sadly, I fear it is just another Policy, someone has dreamed to further his or her career, and bears no relationship to the problems in th NHS in the here and now.

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  • michael stone

    Iama Cynic | 16-Mar-2015 11:27 pm

    I'm a cynic as well - but for end-of-life, a major part of the problem is 'nervousness about the law' rather than any 'lack of caring'.

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  • michael stone | 17-Mar-2015 11:27 am


    you contribute nothing to these threads.



    GO!

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  • michael stone

    When I read on, I came across a really revealing admission in a section about 999 Paramedics:

    106. The Association of Ambulance Chief Executives in their written evidence state that a unified approach to DNACPR documentation is crucial for paramedics and other ambulance clinicians when a swift and difficult decision needs to be taken to allow a person to have a dignified death. They comment:

    Without a DNACPR form or information that establishes that a person is at the end of life, resuscitation may be the course of action decided upon by the clinician that may be later seen as unethical, inappropriate and most importantly not what the patient would have wished for.

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  • michael stone | 17-Mar-2015 2:19 pm

    interesting when the physician-led team arrive 10 minutes after presumed death and start an unsuccessful reanimation on an 86 year old with presumed CCF as they do not know the wishes of the patient! perhaps they are just following their protocol!

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  • When I started my RMN nurse training course in the mid 60's, I was full of hope and optimism, it was all the 'Red Tape', coming from the ministry of health, which put paid to that. I found myself, and a very few others with my attitude, constantly in conflict with my senior nurse colleagues and peers, who, used to be determined to stick by the 'rules' and would not use 'common sense or reasoning'. I didn't go against the Law or policies, I simply did the appropriate basic care that every individual expects and needs. In the end they won, and I left them to get on with it. Didn't THEY do well?
    I think not!

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  • michael stone

    Anonymous | 17-Mar-2015 4:30 pm

    They (999 paramedics) ARE 'just following their protocols'.

    Their protocols are defective - mainly, because 999 paramedics are NOT currently told to ask whoever called them to 'possible EoL situations' "Are you informed about the care of this patient - and if you are involved in that care, what is it we should be doing here ?'.

    Paramedics effectively 'distrust family carers by default' instead of trusting the family by default. Although they are also 'muddled' about various issues around DNACPR and Advance Decisions (in common with a lot of other HCPs).

    I recently exchanged some e-mails with a senior NHS consultant who is involved in EoL and we touched on this issue in the email discussion:

    Consultant’s email included:

    I agree with you that we need to break down the 'inappropriate separations' between the lay person and 'lived-with' person at home and professionals involved in the person's care - but along with that, there is a need to recognise that not everybody has live-with relatives that they trust. Obviously, in the many situations where they do, professionals do need to work with them as a team. In my own clinical experience, that happens a great deal, especially where staff have had a chance to get to know the person and those close to him/her.

    I sent back to the consultant:

    'but along with that, there is a need to recognise that not everybody has live-with relatives that they trust. Obviously, in the many situations where they do, professionals do need to work with them as a team. In my own clinical experience, that happens a great deal, especially where staff have had a chance to get to know the person and those close to him/her.'

    I agree with you - but the problem for EoL at home, is that in complicated and confused situations (an 'early patient death' for example, or an ADRT which 999 Paramedics do not already know about) the family and the paramedics/police 'do not know each other' and, logically, would never be able to 'know each other'. My issue has never been the way interactions with senior professionals tend to go (i.e. with GPs for EoL at home) but with what happens if family are interacting with only junior HCPs, and/or with police officers. I can assure you that arguing the toss around EoL issues with professors 'at leisure', is not the same as trying to get on the same wavelength with paramedics and police officers 'in stressful situations'.

    And the consultant replied with:

    Absolutely agree with you Mike - no easy answers, sorry.

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