Background: Older people living with multimorbidity are projected to become the main recipients of palliative care in the coming decades, yet there is limited evidence regarding their expressed palliative care needs to inform person-centred care. Aim: To understand the palliative care needs of community-dwelling people aged ⩾60 living with multimorbidity in the last 2 years of life. Design: A scoping review following Arksey and O’Malley. Data sources: Three international electronic databases (CINAHL, Ovid Medline, PsycINFO) were searched from March 2018 to December 2021. Reference lists were hand searched. Eligible papers were those reporting empirical data on older people’s needs. Results: From 985 potential papers, 28 studies were included, published between 2002 and 2020; sixteen quantitative, nine qualitative and three mixed methods. Data were extracted and presented under the holistic palliative care domains of need: physical, psychological, social, spiritual, and additionally practical needs. Different measurement tools (n = 29) were used, of which 20 were multidimensional. Primacy in reporting was given to physical needs, most commonly pain and function. Social and practical needs were often prioritised by older people themselves, including maintaining social connections and accessing and receiving individualised care. Conclusion: Identifying the palliative care needs that matter most to older people with multimorbidity requires the recognition of their concerns, as well as their symptoms, across a continuum of living and dying. Available evidence is superficial. Supporting end of life provision for this growing and underserved population necessitates a shift to tailored multidimensional tools and community focussed integrated care services.

Background Post COVID-19 and with anticipated winter pressures, there was a clear need to ensure older people with frailty had timely assessments, with access to high quality end-of-life care and support. Aim To provide a rapid, coordinated response, to improve quality of care and decision making between patients, families and health care professionals across hospital and community settings and reduce hospital admissions from care homes (CH). Methods The CCG funded a dedicated rapid response end-of-life care team: 2 senior nurses (1.6 WTE), medical consultant (0.2 WTE) working alongside existing services. They coordinated inter-agency working through face-to-face and digital communication, prioritising face-to-face review and involvement of relatives. We trialled new approaches to triage requests for support and provided interventions in CHs including quick access to medications, fluids and/or diuretics. Results Over 11 weeks, 138 patients were assessed (mean age 88 ±7.5 years, 68% female). Half had diagnosed dementia, half had clinical frailty score of 8. Two thirds were in nursing homes. 39% were referred by their GP, 24% by the CH and 18% from hospital on discharge. 50% were seen face-to-face on the day of referral; 81% within a week. In 17.4% acute hospital conveyance was avoided by shared decision making between GP, LAS, CH staff and families. Treatment escalation plans were initiated for 56% and updated for a further 32%, including generation of shared electronic care plans. For 50%, single conversations with relatives were needed to support decision making; for a third this was more complex with multiple discussions over time. 36% died, with only 2 deaths in hospital. Whilst COVID affected 18 patients, only 2 of those died. Conclusion Flexible, integrated working enabled patients to receive care and die supported in their usual residence. Care homes need focussed resources and support to hold uncertainty in this disadvantaged group who traditionally don't get access to specialist palliative care.

Background Older people with frailty living in care homes (CHs) are vulnerable to sudden deterioration and death. Unnecessary and unwanted conveyance to hospital could be avoided by robust treatment escalation plans (TEP). However, plans are only useful if accessed at times of crisis when CH staff feel challenged to avoid risk. Aim To introduce a system to improve communication of TEPs between GP, Hospice, Hospital, CH teams avoiding repetition and dependency on electronic systems. Methods Palliative care consultants worked with the Lead GP for CHs in one London borough to 1) integrate electronic record systems; 2) capture key data from conversations; 3) translate information to a patient specific colour coded format; and 4) ensure display and access of TEP by the CH staff in real time. This solution is being trialled over 3 months with the intention that people will receive care in the place they have requested and staff feel more supported. Results TEP generation through EMIS shows a large deficit in the current number of recorded TEPs: 69% of CH residents had TEPs, 32% were patients on the Gold Standards Framework with death anticipated <1yr. Working as part of a pilot project to facilitate excellent end-of-life care in CHs, data showed that the majority of residents/patients and their families are realistic about long-term future when given opportunity to engage in discussions about TEPs. Patients and families were keen to avoid hospital, but importantly wanted reassurance they would receive care that would maintain comfort and dignity. Case studies during this time indicated that TEPs were less likely to be adhered to out-of-hours with poor access to agreed TEPs in CH setting. Conclusion We believe a simple TEP chart generated by the GP, with information shared by the hospice, can be accessed by the CH team to help advocate for CH residents to receive the care and treatment they want.

BackgroundIt is now widely recognised that the palliative care needs of older people with frailty are poorly met compared to those of others at the end-of life (Hamaker, van den Bos, Rostoft, 2020). More people die of frailty and age related comorbidities than of cancer or heart disease and yet they are not the focus of end-of-life care. The COVID-19 pandemic has emphasised the difficulties in providing the right care at the right time for this particular disadvantaged group (Lebrasseur, Fortin-Bédard, Lettre, Raymond, et al., 2021).AimTo improve confidence and capability in (a) hospice and (b) community sectors in understanding and delivering age-attuned palliative care.MethodWe implemented the approach described in Age-attuned Hospice Care (Nicholson & Richardson, 2018). Three phases: (1) Focus groups with key stakeholders, July- Nov 2019;(2) Establish special interest groups to develop resources, July 2020 onwards;(3) Disseminate information locally and nationally, May 2021 onwards.ResultsThe focus groups identified three core capabilities: (1) Assessment of frailty and palliative care needs, (2) Recognition of deterioration and symptom management, (3) Communication around advance care planning (ACP). We established six special interest groups related to frailty: recognition;resource mapping;partnerships;rehabilitation in care homes;dementia;and ACP.Activities to date include: implementing frailty identification as routine practice across the hospice including adaption of electronic systems to plan and audit care, creating proformas for multidisciplinary meetings with GPs and DNs focusing on frailty;devising crib cards for ACP conversations using CLaD intervention methodology and management of frailty related symptoms e.g. delirium and building capability with local partners in rehabilitation and recognition of palliative care need. Early evaluation suggests wide spread adoption and increased confidence and understanding of frailty.ConclusionWe have shown that the palliative care needs of older people with frailty can be enhanced by highlighting information and resources. We plan to cascade further through local and national conferences.

Background Dementia care is complex, especially at the end-of-life. People with advanced dementia suffer from burdensome symptoms; quality of living and dying is enhanced by palliative care (Eisenmann, Golla, Schmidt H et al., 2020). Emphasising personhood (Kitwood, 1997) should be integral to all interactions, providing a safe and nurturing environment in which the person is encouraged to express themselves. This reflects every individual's intrinsic uniqueness and the interconnectedness of human beings. Research from cultural arts interventions has indicated that professionals from the visual and performance arts are well equipped to see the person behind the condition and focus on possibilities for meaningful relationships in the here and now (Swinnen, 2016). Can this translate into everyday care within hospice care? Aim To promote innovative, creative approaches in dementia care, allowing the development of everyday methods to enhance connectivity and care for people living and dying with dementia. Method A programme of immersive, interactive activities and education raising awareness and stimulating discussion, debate and change has been organised (June 2021). Accessible to all members of the hospice team: clinicians, non-clinicians, volunteers, fundraisers and trustees, encouraging the principle that dementia care is everybody's business. Opportunities to engage in creativity to support connection learning with insightful arts and health practitioners/therapists. These include music events, theatre performances, creative sensory workshops exploring senses, movement, texture and sound, interactive exhibitions and a virtual experiential experience. Results Response/learning from these events will be captured using film, questionnaires and focus groups and used to inform and update the hospice's dementia strategy. Key messages will be presented at conference with development of ongoing engagement and future research plans. Conclusion Sharing experiences and displaying new, creative possibilities will aid understanding of those with barriers of memory and communication, unlocking gateways to connection with people living with dementia is possible.

Aim To review our response to support residents and staff in Bromley Care Homes during the COVID-19 pandemic (April 2020–March 2021), reflect on our learning, joint working with colleagues and identify good practice to inform future models of care. Methods We collated clinical activity data and key case reviews of care home patients referred to our service over the year. Contemporaneous notes from formal/informal reflections and debriefs (internal and joint with GPs/CCG/other professionals) were reviewed. Themes from feedback of care home staff and managers (ad hoc and formal focus groups) were included with personal reflections. Results 345 patients were referred from 32 care homes. The majority (45%) in Quarter 1 (first wave), 14% in both Q2/Q3 and 27% in Q4 (second wave). Median age 89(53-110) with 69% >85 years; two-thirds female. 80% had a non-malignant primary diagnosis. Just over half died within the year; median time referral-to-death 17(0-229) days, 81(23%) remained on the caseload April 2021. Key themes in Q1 included: limited effectiveness of virtual assessments, atypical patient presentations, significant impact of social isolation on mental health/function, with families unable to advocate and inconsistent messaging about visiting rights. Care home staff were distressed, burnt out, feeling unsupported. In Q2/Q3 regular GSF meetings with care home-GPs, virtual teaching (webinars/ECHO) and staff 'cascade project' study days helped consolidate learning. The second wave was heralded by an outbreak in extra-care housing; care home-GPs were self-isolating. We led urgent senior clinical review and response. In Q4, daily COVID-19 monitoring meetings were key (representation from CCG, Public Health, Pharmacy, CH-GPs and St Christopher's). Over a month, successive outbreaks were identified and resources coordinated to ensure clear advance care plans, timely review, targeted multiprofessional support to care home staff. Learning from each setting informed changes to approach in the next, including: understanding culture, correcting/enhancing infection control procedures, improved shared decision making and addressing hydration. Conclusion Senior clinical leadership, cross-boundary flexible working and willingness to learn together were vital.