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Care of dying adults in the last days of life [NG31]

Measuring the use of this guidance

Recommendation: 1.1.1

If it is thought that a person may be entering the last days of life, gather and document information on: -the person's physiological, psychological, social and spiritual needs -current clinical signs and symptoms -medical history and the clinical context, including underlying diagnoses -the person's goals and wishes -the views of those important to the person about future care.

What was measured: Proportion of cases with documented evidence within the last episode of care of discussion regarding the patient's spiritual/cultural/religious/practical needs with the patient or the nominated person important to the patient as a proxy for the patient.
Data collection end: May 2015
42%
Number that met the criteria: 3886 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Proportion of cases with documented evidence within the last episode of care of discussion regarding the patient’s spiritual/religious/cultural /practical needs with nominated person(s) important to the patient.
Data collection end: May 2015
38%
Number that met the criteria: 3519 / 9203
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.2.3

Discuss the dying person's prognosis with them (unless they do not wish to be informed) as soon as it is recognised that they may be entering the last days of life and include those important to them in the discussion if the dying person wishes.

What was measured: Proportion of cases with documented evidence within the last episode of care that health professional recognition that the patient would probably die in the coming hours or days (imminent death) had been discussed with the patient.
Data collection end: May 2015
20%
Number that met the criteria: 1898 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Proportion of cases with documented evidence within the last episode of care that health professional recognition that the patient would probably die in the coming hours or days (imminent death) had been discussed with a nominated person(s) important to the patient.
Data collection end: May 2015
79%
Number that met the criteria: 7388 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.2.4

Provide the dying person, and those important to them, with: -accurate information about their prognosis (unless they do not wish to be informed), explaining any uncertainty and how this will be managed, but avoiding false optimism -an opportunity to talk about any fears and anxieties, and to ask questions about their care in the last days of life -information about how to contact members of their care team -opportunities for further discussion with a member of their care team.

What was measured: Proportion of cases with documented evidence that the patient was given an opportunity to have concerns listened to or did not have capacity to raise concerns.
Data collection end: May 2015
84%
Number that met the criteria: 7827 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Proportion of cases with documented evidence that the patient was given an opportunity to have concerns listened to and given an opportunity to have questions answered about concerns or did not have capacity to raise concerns.
Data collection end: May 2015
96%
Number that met the criteria: 2840 / 2936
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Proportion of cases with documented evidence that the nominated person(s) important to the patient during the last episode of care was given regular opportunities to discuss the patient's condition with a senior healthcare professional.
Data collection end: May 2015
80%
Number that met the criteria: 7459 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.3.5

In discussion with the dying person, those important to them and the multiprofessional team, create an individualised care plan. The plan should include the dying person's: personal goals and wishes preferred care setting current and anticipated care needs including: preferences for symptom management needs for care after death, if any are specified resource needs.

What was measured: Proportion of cases with documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care.
Data collection end: May 2015
66%
Number that met the criteria: 6125 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.3.6

Record individualised care plan discussions and decisions in the dying person's record of care and share the care plan with the dying person, those important to them and all members of the multiprofessional care team.

What was measured: Proportion of cases with documented evidence that the team were aware of an individual plan of care for the person that is dying.
Data collection end: May 2015
56%
Number that met the criteria: 5186 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.3.7

Continue to explore the understanding and wishes of the dying person and those important to them, and update the care plan as needed. Recognise that the dying person's ability and desire to be involved in making decisions about their care may change as their condition deteriorates or as they accept their prognosis.

What was measured: Where there is documented evidence that the team were aware of an individual plan of care for the person that is dying, proportion of cases where the care plan was reviewed.
Data collection end: May 2015
86%
Number that met the criteria: 4476 / 5186
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.4.1

Support the dying person to drink if they wish to and are able to. Check for any difficulties, such as swallowing problems or risk of aspiration. Discuss the risks and benefits of continuing to drink, with the dying person, and those involved in the dying person's care.

What was measured: Proportion of cases with a documented assessment of the patient’s ability to drink in the last 24 hrs of life.
Data collection end: May 2015
67%
Number that met the criteria: 6195 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Proportion of cases with evidence that the patient was supported to drink in the last 24 hours of life.
Data collection end: May 2015
45%
Number that met the criteria: 4229 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.4.2

Offer frequent care of the mouth and lips to the dying person, and include the management of dry mouth in their care plan, if needed. Offer the person the following, as needed: -help with cleaning their teeth or dentures, if they would like -frequent sips of fluid.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of mouth care.
Data collection end: May 2015
82%
Number that met the criteria: 5039 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.4.4

Assess, preferably daily, the dying person's hydration status, and review the possible need for starting clinically assisted hydration, respecting the person's wishes and preferences.

What was measured: Proportion of cases with documented evidence that an assessment regarding the patient’s need for Clinically Assisted (artificial) Hydration (CAH) was made at any time between the time of the final admission and death.
Data collection end: May 2015
71%
Number that met the criteria: 6565 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.1

When it is recognised that a person may be entering the last days of life, review their current medicines and, after discussion and agreement with the dying person and those important to them (as appropriate), stop any previously prescribed medicines that are not providing symptomatic benefit or that may cause harm.

What was measured: Proportion of cases with documented evidence (from case-notes or prescription charts including electronic systems) that any of the medications the patient received were reviewed in the last 24 hours of life.
Data collection end: May 2015
65%
Number that met the criteria: 6052 / 9302
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.11

Be aware that not all people in the last days of life experience pain. If pain is identified, manage it promptly and effectively, and treat any reversible causes of pain, such as urinary retention.

What was measured: Proportion of cases where there is evidence documented that symptoms of pain were controlled in the last 24 hours of life.
Data collection end: May 2015
79%
Number that met the criteria: 3867 / 4891
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.12

Assess the dying person's level of pain and assess for all possible causes when making prescribing decisions for managing pain.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of pain.
Data collection end: May 2015
87%
Number that met the criteria: 5350 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.15

Identify and treat reversible causes of breathlessness in the dying person, for example pulmonary oedema or pleural effusion.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of dyspnoea / breathing difficulty.
Data collection end: May 2015
82%
Number that met the criteria: 5000 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.18

Assess for likely causes of nausea or vomiting in the dying person. These may include: -certain medicines that can cause or contribute to nausea and vomiting -recent chemotherapy or radiotherapy -psychological causes -biochemical causes, for example hypercalcaemia -raised intracranial pressure -gastrointestinal motility disorder -ileus or bowel obstruction.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of nausea/vomiting.
Data collection end: May 2015
62%
Number that met the criteria: 3802 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.23

Explore the possible causes of anxiety or delirium, with or without agitation, with the dying person and those important to them. Be aware that agitation in isolation is sometimes associated with other unrelieved symptoms or bodily needs for example, unrelieved pain or a full bladder or rectum.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of agitation/delirium.
Data collection end: May 2015
79%
Number that met the criteria: 4835 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.
What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of anxiety/distress.
Data collection end: May 2015
76%
Number that met the criteria: 4657 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

Recommendation: 1.5.29

Assess for the likely causes of noisy respiratory secretions in people in the last days of life. Establish whether the noise has an impact on the dying person or those important to them. Reassure them that, although the noise can be distressing, it is unlikely to cause discomfort. Be prepared to talk about any fears or concerns they may have.

What was measured: Where there is documented evidence in the last 24 hours of life of a holistic assessment of the patient’s needs regarding an individual plan of care, proportion of care plans which include an assessment of noisy breathing/death rattle.
Data collection end: May 2015
67%
Number that met the criteria: 4077 / 6125
Area covered: National
Source: Royal College of Physicians. National Care of the Dying Audit for hospitals, England.

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