Background Anticipatory prescribing of 'prn' medication for symptom control is recommended for those approaching the last week-of-life however practices regarding anticipatory prescribing for continuous subcutaneous infusions (CSCI) varies widely. The Gosport Report highlighted risks associated with anticipatory prescribing for CSCI. The Association of Supportive & Palliative Care Pharmacy state the perceived benefit does not outweigh the risks. Methods A network-wide cross-boundary audit was undertaken of the use of CSCIs in patients known to specialist palliative care services. A survey was completed by each service-lead and feedback collated following presentation of results. Results 208 of 347 patients (174 hospital, 49 community, 124 hospice) prescribed medication via a CSCI were recognised as likely to be dying. Drugs prescribed included strong opioids (286) anti-emetics (133), anxiolytics (89), anti-cholinergics (102), anticonvulsants (20) and steroids (6). Median doses of opioids and benzodiazepines were low (e,g, morphine 10 mg CSCI q24h) The CSCI had been prescribed in anticipation in 1/5 of patients across all care settings (hospital 20, hospice 24, community 16). 58% of services/organisations responding to the survey allow prescribing for CSCI in anticipation. Feedback following presentation of results and proposed guideline highlighted two conflicting sets of views and practices: anticipatory prescribing for CSCI as vital to ensure timely symptom control in the dying vs. the view it is unsafe practice, citing incidents/near-misses resulting from lack of clinical assessment of need at the time a CSCI is commenced. This audit reviewed current practice but is unlikely to capture such clinical incidents or 'near-misses' where drugs are administered without indication or at high doses. Conclusion There is conflicting practice and opinion surrounding the risks and benefits of anticipatory prescribing for CSCI. This audit did not identify unsafe practice but will not reliably capture incidents or near-misses. Further evidence-based national guidance is required to guide safe practice.

Background The Palliative Care population represents a heterogenous group of patients with variable risk factors for bleeding and venous thromboembolism (VTE). Decisions about VTE treatment and primary prophylaxis can be challenging in these patients. Aim The aim of this audit was to evaluate the management of anticoagulation in the hospice, hospital and community settings against current guidelines. The results of this audit, in addition to an extensive systematic review, informed the update of regional guidelines for the management of anticoagulation in Palliative Care Patients. Methods A retrospective case note review was carried out across a regional palliative care network in North West England. Results 189 patient records were analysed across 12 different sites within the region. 70% of patients were in hospice, 23% in hospital and 7% in the community. Of 89 patients on treatment dose anticoagulation, only 9% had the intended duration of anticoagulation documented. Of 60 patients on treatment dose low molecular weight heparin (LMWH), weight was documented in 63%. Renal function was documented in 88% of patients on LMWH, and in 75% of 24 patients on treatment dose direct oral anticoagulants (DOACs). 71% (66/93) had a venous thromboembolism assessment completed. Prophylactic anticoagulation was given in 43% of these 93 patients. For prophylaxis, the majority (90%) received LMWH, with the remaining 10% prescribed a DOAC. 42 patients died during the episode of care. The anticoagulation (either primary prophylaxis or treatment) was continued until death in 43% of these patients. Conclusion Clear documentation of anticoagulation duration, and factors which influence choice of anticoagulant and dose (eg renal function and weight), are important for safe prescribing. These results have influenced the content of a regional guideline to enable healthcare professionals to make effective, evidence-based and patient-centred decisions about anticoagulation in patients with a life-limiting illness.

Background Bereavement is defined as the state of a loss when someone close to you has died. It is important that people closely affected by a death are communicated with in a sensitive and timely manner and that those at risk of pathological bereavement reactions are identified and supported. At a tertiary cancer centre it was recognised that families need time and support soon after the death of their loved one. Aim To deliver a ‘day after death’ service providing personalised bereavement support to families/carers and learn lessons about care by discussing their experiences. Methods At our tertiary cancer centre we implemented an innovative 4 step approach to supporting bereaved families and carers: Comprehensive documentation including a bereavement risk assessment at the time of death. Innovative ‘day after death’ service. Post bereavement contact if accepted. Face to face follow up where required. The bereaved families/carers meet with a senior member of the Nursing Team who knew the patient on the next working day. They meet in a private room away from the wards and discuss how they are coping with their loss and listen to any questions/concerns they may have. The relevant paperwork is then provided. This also provides the opportunity to follow up the bereavement risk assessment undertaken by the ward staff. Following the meeting a reports is shared with the Director of Nursing and discussed at the Trust Executive meeting. Results There have been 84 deaths within the tertiary cancer centre in the last 12 months. All bereaved families/carers have received the day after death service. This has enabled us to provide comprehensive and personalised bereavement care. It also enables us to identify those people likely to have complex bereavement and signpost to local specialist support services. Conclusions We have successfully implemented a 4 step innovative service delivering personalised bereavement care.

Background: Enhanced supportive care (ESC) promotes the earlier implementation of supportive care within cancer care. While earlier supportive care has been demonstrated to improve patient outcomes, the model of delivery is variable. The Clatterbridge Cancer Centre has developed a multi-professional delivered model with clinical nurse specialists providing ongoing patient review and care. Method: A retrospective single-system design was used to assess longitudinal changes in Integrated Palliative Care Outcome Scale (IPOS) scores as indicators of quality of life. For other outcomes, a retrospective case control analysis was undertaken. Results: Statistically significant improvements in all IPOS scores were observed for patients attending ESC. Compared to controls, quantitative outcomes included prolonged survival and reduced chemotherapy-related mortality. Multi-professional delivered ESC successfully improves quality of life and outcomes.

Background In 2014 the family of a woman who died in one of Britain’s best-known hospitals won their legal claim that her rights were violated when a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) document was completed without her or her family being consulted. A judicial review noted that Article 8 of the Human Rights Act was breached, concluding that there is a duty to consult patients and/or those important to them in relation to DNACPR unless that consultation may result in physical or psychological harm; this is more than just causing distress. Aim Audit practice regarding DNACPR decisions and the discussions surrounding them in a tertiary cancer centre. Methods A retrospective case note review of patients‘ in whom a DNACPR had been placed was conducted in December 2016. Practice was compared against the 2016 Joint Statement, ‘Decisions relating to cardiopulmonary resuscitation’. Results 22 case notes were reviewed in which a DNACPR was completed; 19 due to futility in cases of terminal cancer and 3 due to patient choice. In 3 cases no consultation had taken place. The reasons for this included patient/family declining a discussion and risk of harm. In 4/22 cases there was no documentation of the clinical reasoning for a DNACPR decision. In 1 case the consultation led to potentially avoidable patient distress. In 7 cases the patient lacked mental capacity to participate in a consultation; in 1 case it was felt it would cause too much harm to discuss the decision with their family. Conclusion Patients and those important to them should be made aware of DNACPR decisions and these conversations recorded, including reasons for the decision. This audit however has highlighted ongoing variability in practice. Further training is needed in order to standardise practice and ensure high quality consultations around this sensitive topic are undertaken.

Background Grief is a natural response to the loss of a loved one but can have the potential for long term adverse effects. Bereavement services are therefore essential to provide support and to identify those at risk of harm. A ‘day after death service’ for bereaved persons is a longstanding component of bereavement care at our tertiary cancer centre. Bereaved persons are met by a clinical nurse specialist the day after the death for a face to face discussion and support needs assessment. This system aims to improve support and identify those at risk of pathological grief reactions. Aim Conduct a quality improvement project aimed at enhancing bereavement support at our centre by incorporating feedback from bereaved persons into trust-wide education and care quality indicators. Methods A 12 month retrospective audit was undertaken to evaluate bereavement service outcomes.This was combined with feedback from stakeholders to develop a PDSA quality improvement cycle. Results At baseline 51 deaths were recorded in 12 months. 42 people agreed to ongoing support following accessing the day after death service. 39 people did not require any further support following a single phone call. Three bereaved persons needed additional support due to prolonged/pathological grief, and were supported appropriately. Stakeholder satisfaction surveys revealed an 88% approval rating for emotional support and practical help, and 100% would recommend the service to others. Qualitative constructive feedback suggested enhancing methods of detecting people at high risk of pathological grief and developing an action-orientated approach to bereavement support. Conclusion Bereavement care incurs practical as well as emotional challenges. Despite positive feedback regarding the emotional support provided by our service, there are practical areas for development. The next step of our project is to incorporate these changes into education and information processing tools, before re-evaluating progress.