EAPC - ipac

426 EAPC Abstracts
palliative care is particularly limited. Conclusions: Hospice accessibility has
implications for the establishment of further hospices and highlights the need
to consider the remit of alternative palliative care services in areas without
local access, as well as for deprived communities.
89 Oral Presentation
Organisation of Care and Services
Improving generalist palliative care services for adults at the
end of life: what more do we need to know
Authors: Cathy Shipman Department of Palliative Care & Policy King’s
College London UNITED KINGDOM
Scott Murray University of Edinburgh Edinburgh UNITED KINGDOM
Marjolein Gysels King’s College London London UNITED KINGDOM
Sarah Forrest University of Cambridge Cambridge UNITED KINGDOM
Stephen Barclay University of Cambridge Cambridge UNITED KINGDOM
Patrick White King’s College London London UNITED KINGDOM
Allison Worth University of Edinburgh Edinburgh UNITED KINGDOM
Steve Dewar King’s Fund London UNITED KINGDOM
Marilyn Peters King’s College London London UNITED KINGDOM
Suzanne White King’s College London London UNITED KINGDOM
Irene J Higginson King’s College London London UNITED KINGDOM
Background: Most end of life care is provided at home, in care and nursing
homes and hospital by generalists rather than specialists in palliative care.
The importance of generalist care is recognised in current policy, but little is
known about provision. The study aimed to identify issues, gaps in provision
and research to improve generalist end of life care. Methods: A national consultation
was undertaken in England and Scotland using a modified nominal
group technique. 285 commissioners, generalist and specialist palliative care
providers, academics, voluntary and user groups were invited to participate.
Data was collected by email, face-to-face and telephone interview in 5 different
areas, and a thematic analysis undertaken. Key priorities were agreed by
participant votes. Results: 210 participants (74%) took part in the consultation
across London, Cambridgeshire, Warwickshire and Scotland. There was
little consensus about what constituted generalist end of life care. Perceived
gaps in provision included care of non-cancer patients, older people and
minority groups. We identified much enthusiasm for providing excellent end
of life care, but engaging some generalists in education and training was difficult.
A greater evidence base was needed for tools such as the Gold
Standards Framework and Liverpool Care Pathway. Workforce and financial
issues limited provision. More needed to be known about best practice, place
of care and integrating end of life care into generalist caseloads.
Understanding more about patient and carer experiences and health economic
implications was central to generating a good evidence base. Conclusions:
Generalist end of life care takes place in many different settings, amongst
many competing priorities. Given its importance, lack of research to underpin
best practice is surprising. Current policy developments in England are
welcomed but need a strong evidence base to ensure sustainability. Funder:
National Institute for Health Research SDO Programme, England.
90 Oral Presentation
Organisation of Care and Services
Can we prevent emergency hospital admission of older people
at the end of life Methodologies, challenges and findings from
the first wave of data from the COPEC study
Authors: Barbara Gomes Palliative Care, Policy & Rehabilitation Cicely
Saunders International/King’s College Londo UNITED KINGDOM
Rachel Burman King’s College Hospital NHS Trust London UNITED
KINGDOM
Andy Parfitt Guy’s & St Thomas’ NHS Foundation Trust London UNITED
KINGDOM
Irene J Higginson King’s College London, Department of Palliative Care,
Policy & Rehabilitation London UNITED KINGDOM
Ed Glucksman King’s College Hospital NHS Trust London UNITED
KINGDOM
Laura Skingle King’s College London, Department of Palliative Care,
Policy & Rehabilitation London UNITED KINGDOM
Teresa Beynon Guy’s & St Thomas’ NHS Foundation Trust London
UNITED KINGDOM
Background: Most older people die in hospital and numbers of 65’s and
over (65+) at Emergency Departments (EDs) are increasing. COPEC study
– Care for Older People in Emergency Care – aims to 1) describe
reasons/patterns of admission for 65+ to two EDs in London 2) assess
palliative need amongst the group 3) investigate whether admissions were
preventable. Methods: Review of records of all patients 65+ who died/were
admitted at EDs at King’s College Hospital or Guy’s and St Thomas’
Hospital (Nov06–Oct07). The hospitals serve a population of 760,000,
77,300 aged 65+. Data from 3 databases at each site were analysed to
describe patient profile and reasons/patterns for death/admission. Review of
case notes for a random sample will describe palliative need and assessed
preventability of admissions. Results: In one year, there were 27,543 attendances
of 65+ across the two EDs (11.7% of all ED attendances): 130 died
at ED (46.3% of all ED deaths) and 51.9% were admitted (28.6% of all ED
admissions). First phase findings at King’s College Hospital show that of
those died/admitted, 48.0% came in out-of-hours (59.3% in weekdays,
6pm-8am) and 45.1% presented alone. Problems most frequently recorded
at ED were shortness of breath (12.1%), falls (10.5%) and chest pain
(8.2%); diagnosis was unknown in 89.1% of cases. Approvals for use of
data where patient consent was unfeasible took 5 months (40% of project
time), granted by 4 organizations. Conclusions: Older people are frequent
admitted at EDs and patterns suggest isolation and lack of alternatives
during out of hours. Nearly half of deaths at ED are from 65+.
Breathlessness appears to be a critical symptom but there may others. A
greater understanding of the population and care pathway should trace end
of life models in emergency care. On behalf of COPEC project team.
Funded by Guy’s & St. Thomas’ Charity and King’s College Hospital
Charity.
91 Oral Presentation
Organisation of Care and Services
Metastatic spinal cord compression and rehabilitation: explaining
unintended consequences in a health care organisation
Authors: Gail Eva Nuffield Department of Medicine University of Oxford
UNITED KINGDOM
John Paley University of Stirling Stirling UNITED KINGDOM
Bee Wee University of Oxford Oxford UNITED KINGDOM
Background: Metastatic spinal cord compression (MSCC) is a cause of
significant disability. In other conditions (stroke, for example) such disability
would merit a patient’s participation in a rehabilitation programme.
Patients with MSCC, however, are not routinely provided with structured
rehabilitation. This study was designed to examine the processes involved
in the provision (or lack) of rehabilitation in MSCC, in order to identify the
mechanisms implicated in service delivery. Methods: The design was a
series of 9 process-tracing, longitudinal case studies, involving 58 interviews
with patients, carers, rehabilitation staff, nurses and doctors in one
NHS region. A context-mechanism-outcome data collection strategy was
used, together with a grounded theory constant comparative method of data
analysis. Results: Patients described inadequate rehabilitation, for example:
little information on practical issues like incontinence, provision of equipment
without consideration of the psychological aspects of disability,
discontinuity between hospital and community services. These problems
prevailed despite support for rehabilitation and the existence of arrangements
for its provision. Conclusions: ‘Deficiency explanations’ are often
used to explain undesirable outcomes: a lack of resources, or time, or skills,
or staff. These answers are not entirely wrong, but here they are incomplete
and misleading. Complex adaptive systems (CAS) theory offers an alternative
explanation for unintended consequences, with outcomes the result of
several ‘agents’ acting independently, and in accordance with a set of ‘rules’
or mechanisms. CAS might prove useful in health care to explain structures