| Back to main Menu |
| Back to Clinical |
1Z01. Terminal illness - late stage
8BA2. Terminal care
8BAP. Specialist palliative care
8BAS. Specialist palliative care treatment - daycare
8BAT. Specialist palliative care treatment - outpatient
8BJ1. Palliative treatment
8CM1. On gold standards palliative care framework
8CM4. Liverpool care pathway for the dying (v12)
8H6A. Refer to terminal care consult
8H7L. Refer for terminal care
8H7g. Referral to palliative care service
8HH7. Referred to community specialist palliative care team
9EB5. DS 1500 Disability living allowance (terminal care) completed
ZV57C [V]Palliative care
The definition of palliative care is the active total care of patients with a life-limiting disease, and their families, by a multi-professional team. Use of palliative care registers to improve care for the most seriously ill has increased (estimated at 89%) since the introduction of this indicator as part of the previous QOF revisions. There is increased recognition of the need for high standard palliative care provision by GPs and primary care teams and one such example of good practice, the Gold Standards Framework (GSF) for community palliative care, was noted in the NICE Guidance for Supportive and Palliative Care 2004, in the NHS End of Life Care programme 2005 (www.endoflifecare.nhs.uk) and in the White Paper ‘Our Health Our Care Our Say.’
The GSF, a widely implemented programme of care for palliative
care patients, is now associated with a considerable degree of research and
evaluation and is key to thinking through and implementing high quality patient
centred care at the end of life for patients with both cancer and non cancer
diagnoses.
www.goldstandardsframework.nhs.uk
About 1% of the population die each year (over half a million); a quarter from cancer, a third from organ failure, a third from frailty or dementia, and one twelfth have a sudden death. This represents an average of 20 deaths per GP per year.
The prognostication of likely disease progression is very difficult for both cancer and non cancer patients. Clinical prediction of survival is not an exact science with errors (defined as more than double or as less than half of actual survival), 30 per cent of the time. Two thirds of errors are based on over optimism and one third on over pessimism.
However there are considerable benefits in attempting to recognise the point at which an illness becomes advanced or end stage in order to mobilise best care for patients, and address the likely health and social care needs of patients and their families.
The NHS Cancer Plan (2000) acknowledged that support for patients living at home with advanced cancer is sometimes poorly coordinated and may not be available 24 hours a day. Moreover, it acknowledged that cancer patients should be able to live and die in the place of their choice wherever possible. Between 50 and 90% of patients with cancer, when they express a wish concerning place of death, would choose to die at home. Patients expression of their preferred place has been linked with actual place of death, showing more patients achieve a home death if they have expressed a wish to do so. In addition, patients and carers agreeing on home as the preferred place of death has been shown to be a strong predictive factor in achieving a home death.
Therefore identifying patients in the advanced stage of their illness in need of palliative/ supportive care, assessing their needs and preferences and proactively planning their care, are three key steps in the provision of good end of life/ primary palliative care. This is why this new indicator set is focused on the maintenance of a register for patients, identified against certain criteria of prognosis and need, and on regular multidisciplinary planning meetings.
Further information: DOH, The NHS Cancer plan: a plan for investment, a plan for reform. 2000, Crown Copyright: London.
Criteria for inclusion on the register are consistent with prognostic criteria for advanced disease described in the GSF and with the use of the DS 1500.
A patient should be included if:
1. their death in the next 12 months can be reasonably predicted
and/or
2. they have clinical indicators of need for palliative care that are prognostic clinical indicators of advanced or irreversible disease and include 1 core and 1 disease specific indicator in accordance with the GSF. www.goldstandardsframework.nhs.uk/gp_contract.php
and/or
3. they are the subject of a DS 1500 form. (The DS 1500 form is designed to speed up the payment of the Disability Living Allowance, Attendance Allowance or Incapacity Benefit. It is usually issued when the patient is considered to be approaching the terminal stage of their illness. In Social Security law a patient is terminally ill if they are suffering from a progressive disease and are not expected to live longer than six months).
The register is prospective from 1 April 06 and applies to adults over the age of 18 years.
The creation of a register will also enable the wider practice team to provide more appropriate and patient focussed care e.g. reception staff will be aware of the need to prioritise communications from relatives to clinical staff if the patient in question is on the register.
The practice reports the number of patients on its palliative care register.
Verification – in the case of a nil register at year end, if a practice can demonstrate that it had a register in year then it will be eligible for payment.
The practice has regular (at least 3 monthly) multidisciplinary case review meetings where all patients on the palliative care register are discussed.
The aims of the case review meetings are to:
• improve the flow of information (particularly out of hours and
between different teams)
• ensure that each patient has a management plan as defined by the practice
team and that decisions are acted upon by the most appropriate member of the
team
• ensure that the management plan includes preference for place of care
• ensure that the support needs of carers are discussed and addressed where
ever reasonably possible.
The practice should submit written evidence to the PCO describing the system for initiating and recording meetings.
Prepared By Jean Keenan