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Steps to improve the physical setting in end-of-life care

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The Department of Health has announced new funding to improve the standard of
care settings for dying patients and bereaved relatives. Nerys Hairon reports

The Department of Health has recently announced 1m of funding to improve the physical environment of NHS services caring for patients at the end of life (DH, 2008; NT News, 20 May, p5). Nurse-led teams in 19 NHS trusts and a prison will carry out work to improve facilities for patients at the end of life, bereaved people and staff caring for them.

The range of projects will include new palliative care beds, improved facilities for families and visitors, dedicated bereavement suites and refurbished mortuary viewing facilities. Each project is required to physically improve an area used by patients and relatives, and must be run by a nurse-led, multidisciplinary team. Involvement of patients and relatives will form an integral part of project planning.

The funding announcement indicates an increasing emphasis on the quality of end-of-life care. It comes ahead of the government’s end-of-life care strategy, set to be launched next month. This strategy is intended to give people greater choice and improved care at the end of life.

The new programme is the latest phase of the King’s Fund’s Enhancing the Healing Environment (EHE) programme, and follows a pilot scheme in eight sites on end-of-life care, completed earlier this year.

The King’s Fund has published a report outlining the lessons learnt from these pilot sites, known as the Environments for Care at the End of Life (ECEL) programme (Waller et al, 2008).

This report includes a literature review on the evidence for improving palliative care environments, an analysis of the lessons learnt from the pilot sites, and key recommendations for the improvement of care facilities.

Key findings

Literature review

The literature review in the King’s Fund report aimed to identify research describing the impact of the environment on end-of-life care. Waller et al (2008) say that the most striking finding was the relative lack of research literature, although some significant pointers towards positive therapeutic environments did emerge.

The authors argue that the environment for end-of-life care should be of fundamental concern for policymakers and NHS managers. The review identified a number of factors that were frequently reported as encouraging well-being and likely to be important to people at the end of their lives.

The characteristics of a therapeutic setting at the end of life were identified as: home-like environments; single rooms; facilities for family members; natural light; design that incorporates elements of nature; soothing colours and artwork; windows with views; being able to enjoy pleasant sounds; and having access to outside space and gardens.

In addition, there were some concerns raised in the literature that are unique to end-of-life care. These included transfer of the body to the mortuary, relatives’ journey to the mortuary, viewing rooms and bereavement rooms.

The researchers found the literature very informative on those aspects of the environment that are not conducive to quality end-of-life care including: noise; lack of privacy; crowded rooms; lack of appropriate seating for patients and lack of amenities for families staying at care services (Kayser-Jones et al, 2003).

In addition, the review found that nurses on general medical wards reported that physical surroundings reduce the quality of the care they are able to provide to dying patients. These factors include the lack of private patient rooms, lack of telephones in patient rooms and drab interior design (Thompson et al, 2006).

Improving the environment

Four of the eight projects carried out by the pilot group focused on mortuary viewing facilities. The remainder focused on redesigning a visitors’ room, improvements to a bereavement suite, the creation of palliative care rooms, and the redesign of patient rooms in a hospice. Each team was asked to undertake early and ongoing consultation with patients, families and staff, which needed to be carried out with sensitivity.

Many of the teams, especially those that focused on improving mortuary viewing suites, found that bereavement policies were either out of date or poorly communicated. Waller et al (2008) state that the revision of these procedures has been a common and significant wider benefit of the work.

One NHS trust in the pilot programme created a palliative care facility in one of its hospitals. The project team decided to convert a four-bed bay at the end of a ward into two en-suite rooms specifically designed for patients with palliative care needs. The ward staff already cared for some patients with such needs and the plan was that they, together with the trust’s palliative care team, would deliver care to patients in the suite, with the aim of stabilising them in preparation for discharge home.

The team sought the views of patients being looked after by the palliative care team on aspects of design, colour, lighting and atmosphere. The aim was to create rooms that would be calm, quiet and encourage family and friends to visit.

The team decided to use natural materials and colours throughout the suite, and for fixtures and fittings to be of a hotel standard. Both rooms were furnished in the same style and care was taken in choosing furniture. The team also made great efforts to ensure that patients could have as much control over the environment as practicable, through lighting, television and temperature control.

For details on other examples in the pilot scheme, and ‘before’ and ‘after’ pictures, see the full report at kingsfund.org.uk.

Recommendations

Waller et al (2008) argue that the environment is a crucial consideration in initiatives aiming to transform service development and delivery for dying patients and bereaved people.

As a result of the literature review and practical experience, the authors recommend the DH and other organisations call for and support further research on the environment in end-of-life care. This research should investigate: how dedicated end-of-life care settings should make people feel; the use and acceptability of language and signage related to palliative care environments; and how best to involve dying people and bereaved relatives in the design and delivery of services. The authors make a range of recommendations for all settings in which end-of-life care is delivered (see box).

Improving care settings

All settings in which end-of-life care takes place should provide:

  • A room where patients and families can be taken for confidential discussions;

  • The option of single-room accommodation designed to promote a feeling of homeliness where patients retain control over their environment;

  • Informal gathering spaces and places where families can meet, confer and talk with care staff;

  • Guest rooms where close family or friends can stay overnight with catering facilities and internet access;

  • Appropriate places for viewing deceased people.

In addition, all health service providers should include the care of dying patients, bereaved and deceased people in corporate induction programmes for all staff. Professional training for all staff groups should include material on the impact of the environment in end-of-life care. The authors also recommend that all staff should be made aware of the need to recognise and respect the essential ‘personhood’ of deceased people in all areas and departments of the healthcare organisation.

Finally, the DH should develop national standards for the environment for end-of-life care and significantly increase investment in these environments. The department should ensure that policy and practice development enables everyone to make choices about where they would prefer to die and to revisit that choice as their condition changes.

Conclusion

Since 58% of deaths occur in NHS hospitals (DH, 2008), it is vital that nurses are aware of the environmental factors that impact on end-of-life care.

The literature review in the King’s Fund report illustrates both positive and negative factors, while the pilot group examples show how to improve care settings for dying patients and bereaved people. With the government’s forthcoming end-of-life care strategy expected this summer, this area of care is set to move higher up the political agenda.

References

Department of Health (2008) Dying Patients and the Bereaved to Benefit From Department of Health Investment in Hospital Environments. Press release, 15 May 2008. dh.gov.uk

Kayser-Jones, J. et al (2003) Factors that influence end-of-life care in nursing homes: the physical environment, inadequate staffing, and lack of supervision. Gerontologist; 43: 2, 76–84.

Thompson, G. et al (2006) Nurses’ perceptions of quality end-of-life care on an acute medical ward. Journal of Advanced Nursing; 53: 2, 169–177.

Waller, S. et al (2008) Improving Environments for Care at End of Life. Lessons from Eight UK Pilot Sites. London: King’s Fund.

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