End of Life Care in Older people
PEACE
Dr Elena Mucci
Consultant Physician in the Care of Older People
Department of Medicine for the Elderly
Conquest Hospital
Aims and Objectives

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Statistics: ageing population
Palliative and End of Life Care for Older
People

End of Life Care policy
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Conquest admissions data

PEACE tool
The Ageing UK Demographic

“The absolute number of older adults and their proportion in the
population is significantly increasing”- Deaths in older adults: National EOL care
intelligence network

People >75years:
1983–2008, Population increased by a third:
2.9million(6%) to 4.0million people(8% total pop).

People 85 years and older:
1985-2010, Population more than doubled:
690,000 to 1.4 million people(2% total pop).
Projections (Office for National Statistics):
By 2033 people aged 75 and over are projected to increase to 7.2 million
People aged 90+, 0.4 million (2008) to 1.2 million in 2033.
Source: Mid-year population estimates, UK Office for National Statistics.
Care of the Elderly in the NHS
• Francis Inquiry: “many of the cases in which patients and their families
have reported concerns have involved elderly patients”, 2005-2009.
• National Confidential Enquiry into Patient Outcome and Death
(NCEPOD): Nearly 40 per cent of people who died within four days
of being admitted to hospital received less than good care, 2009
• Care Quality Commission: Elderly suffer poor care in half of NHS
hospitals, 2011
• Health Service Ombudsman report: Principles and values of the NHS
Constitution are not followed, 2011
• National Audit of Dementia care: the encounter between staff and
patients was “mainly task-related and delivered in a largely impersonal
manner”, 2012
Palliative and End of Life Care (EoLC) of Older People:
Nationally approved tools and suggested practice
2003 DOH: Building on the Best, set out to extend choice to all those
approaching the end of their life, not just those with cancer.
2004:National End of Life Care Programme (NEoLCP) , specific objectives
of improving the quality of care for all and enabling more patients to
live and die in the place of their choice.
2008: End of Life Care Strategy, framework aimed at promoting high
quality care across the country for all adults approaching the
end of life.
2008: End of Life Care Strategy 'Promoting high
quality care for all adults at the end of life'.
• Identification of people approaching the
end of life and initiating discussions about
preferences for end of life care;
• Care planning: assessing needs and
preferences, agreeing a care plan to reflect
these and reviewing these regularly;
• Coordination of care;
• Delivery of high quality services in all
locations;
• Management of the last days of life;
• Care after death; and
• Support for carers, both during a person’s
illness and after their death.
EoLC Policy
• The White Paper “Equity and Excellence: Liberating the NHS”: “In EoLC, we
will move towards a national choice offer to support people’s preferences
about how to have a good death...”
• NHS Outcomes Framework included EoLC in Domain 4 “Ensuring that
people have a positive experience of care”, under 4.6 “Improving the
experience of care for people at the end of their lives”
• EoLC is one of the 12 work streams within QIPP initiative: seeks to align
the quality and productivity agenda. The quality indicator adopted by
QIPP- “Proportion of Death in Usual Place of Residence”
• NICE published 16 quality standards for EoLC which are themed around
the concept of whole systems approach to holistic care provision in the
end of life.
EoLC statistics
• Only 40.8% die in their usual place of residence.
• 70% say they want to die at home.
• 50% have 2 or less unplanned admissions in the last year of
life.
• 20% have 5 or more.
• Each admission cost on average £3000.
• 20% of beds are occupied by dying people who have no
medical reason to be in hospital.
• Prevention of one unnecessary hospital admission for only
10% of those who die each year will save £132 million on the
tariff and enable 44,000 people to have a better death.
National end of life care programme: NHS based
delivery arm of the EOLcare strategy.
Discussions as
end of life
approaches.
Advance Care Planning (ACP)
Patients considering and recording their wishes and preferences
for future care at the end of life. Originating from Preferred Place of
Care.
Gold Standards Framework (GSF)
Assessment, care
planning and review.
Co-ordination
of care.
Evidence based approach comprising of multiple tools to optimize the care
for patients nearing the end of life. It includes care in the final year of life for
people with any end stage illness. This model of delivery is for both primary
care and care home settings. The Acute Hospitals Programme (Phase 3)
started January 2012.
Care in the last
days of life.
Care after death
Liverpool Care Pathway (LCP)
Care of the dying in the last hours and days of life. Various models for
application in different settings-phased out, August 2013
Admissions data, Conquest: Sept10-Aug11:
Patients aged 76 and over


Figures not inclusive of MAU admissions
4402: total admissions via A&E For patients aged 76 and
over

2530: Single admissions

43% of all admissions, were
readmissions within this cohort.
Admissions data, Conquest: Sept10-Aug11:
Patients aged 76 and over
PEACE project
Proactive Elderly Person’s Advisory CarE Planning tool
(PEACE)
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•
•
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Advance Care Planning
PEACE project
End of Life Care, time to change
Case presentation
Advance Care Planning
 A process of discussion between an individual, their care
providers, and often those close to them, about their future
care. The discussion may lead to:
– An advance statement
– An advance decision to refuse treatment
– The appointment of a personal welfare LPA
Background
• Advance Care Planning National Guidelines (RCP 2009) – Note MCA
central to making valid clinical decisions
– No single tool recommended
– ACP should be offered during routine clinical practice ideally in
primary care
– Discussions should be skilfully led
PEACE
• Developed and used by Geriatricians at
KCH&STH
• Recently adopted at Lewisham hospital
• End of life care planning tool for NH patients
in primary and secondary care.
Difference between PEACE and LCP
• The LCP was developed by a MDT specialising in
hospice care to enable staff in hospitals and in the
community to deliver evidence based end of life
care. This pathway is only to be used in the last few
days of life (the dying phase).
• PEACE is end of life care planning for patients with
worsening chronic conditions who have less than 12
months to live.
Examples of PEACE
• End stage PD-recurrent aspirations.
• Advanced dementia-recurrent dehydrations,
not E&D.
• Severe disabling stroke-no rehab potential,
poor quality of life.
• End stage COPD/CCF-recurrent exacerbations.
• Frailty of old age.
• Cancer
MM
• 94 year old lady, NH resident for 6/12
• 3rd admission with increased confusion in the
last 12 months.
• Dehydrated
• Bed bound, fully dependant, dementia
• Spoke to the son and the NH Matron- EoLCP
done, not for further hospital admissions,
unless comfort measures fail.
MB
•
•
•
•
98 year old, lives alone independent
Multiple co-morbidities, daughter helps
EoLC discussed, ACP offered in OP
Patient does not want any interventions, not
even antibiotics, wants DNAR, and wants to
die at home-daughter did not have a clue
about her wishes!
Aims of PEACE
• To improve communication in the transfer of clinical
information between hospital and care home
• To provide an individualised document that records the
suggested action plans on progression of illness which have
been discussed with patients, relatives and carers by hospital
specialists in the care of older people.
• Contribute to advance care planning
• Reduce inappropriate hospital readmissions
• Improve the quality of care at the end of life
PEACE – Page 1
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Suggested Action on Progression of Illness
Possible developments identified
Three action categories
Intensive Hospital: Consider transfer to hospital for treatment;
intubation, ventilation etc. to be considered.
Non–Invasive Hospital: Consider transfer to hospital for treatment.
Avoid intubation and ventilation.
Nursing Home: Aim to give treatment, medication and comfort
measures within the nursing home with support from GP and
other services e.g. Hospice at Home or community specialist
palliative care nurses. Aim to avoid admission to hospital unless
measures fail. If patient starts to approach last days/weeks of life
and in particular finds swallowing increasingly difficult, consider
asking GP to prescribe injectable End of Life medications (if not
already available). If the patient is in the last few days of life,
consider implementing the Liverpool Care Pathway.

Individual advice – specific to development
Example
Possible developments Action
category
Comments
Aspiration due to
delayed swallow
Nursing
Home
Follow SALT advice on positioning. On
puree diet and sips, position upright. If
fatigue noted allow to rest then resume
feeding
Dehydration due to
reduced oral intake
Nursing
Home
As above. Allow plenty of time to help .
Avoid future hospital admissions for
this.
Recurrent infections
Nursing
Home
Trial of PO antibiotics by GP if
appropriate. Consider referral to
palliative team should future
deterioration occur.
PEACE – Page 2
 Mental
capacity
PEACE – Page 3
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
Summary of discussions with NOK
Resuscitation status
Page 4
• Guidance and important contacts.
Key questions for MDMs
Yes
Is the patient for
transfer to a
nursing home?
No
Go to next question
PEACE not
applicable
Is the nursing home Go to next question
in Hastings and
Rother region?
PEACE not
applicable
Has the patient got
an existing PEACE
or Advance Care
Plan in place?
Complete PEACE
Review and update
existing document
PEACE plan CHECKLIST
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•
•
•
•
•
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Patient is a NURSING HOME* resident
Discussed at MDT meeting-for PEACE
Discussed with patient and/or NOK-agreed for PEACE
PEACE documentation completed
GP informed by a doctor prior to discharge
Nursing home informed by a doctor prior to discharge
PEACE is mentioned at nurse handover prior to discharge
*Some Residential Homes except patients for end of life care.
Please discuss with the home Manager prior to discharge. A
member of staff from a Residential Home must review PEACE
patients prior to discharge.
PEACE audit
Demographics and basic data
• 42 patients (38% males, 62% females)
admitted to the Conquest Hospital were later
discharged on PEACE documentation between
13/02/2012 and 13/08/2012.
• 120 patients up to now
• The average age of patients was: 86.7 years
Mental Capacity
Only 66% of patients
had dementia or cognitive
impairment recorded
at the time of admission,
90.5% of patients were
assessed as lacking the
capacity to make future
care decisions at the time
of the PEACE discussion
Reasons for admission
Discharge destination
• During the study period, 81% were discharged to NH
and 19% were discharged to RH
• 23 different care homes in Hastings and Rother
receiving a patient on the PEACE.
• At the end of the audit time-August 2012- 45% of the
patients were still alive with a PEACE plan and 55%
had died.
• The average survival from PEACE plan to death was
32.5 days.
PEACE readmissions
PEACE plan: followed
• 98 year old man from a RH
• 1st admission:18/05/12-14/06/12 (4 weeks)
with biliary sepsis, became very frail, RH could
not meet his needs, placed into a NH with his
wife with PEACE plan.
• No hospital admissions in the previous 12
months.
• Patient has capacity to consent to PEACE
PEACE plan: followed
• 2nd admission: 20/09/12-26/09/12 (6 days)appropriate admission as per patient’s wishes,
discharged on updated PEACE plan.
PEACE plan: followed
• RIP on 18/11/12 (53 days later) peacefully at
his NH with input from H&H team.
• I interviewed the NH: found the pathway
useful, GP felt she had enough support in
making EoLC decision and H&H team new
about the patient and helped at a short
notice.
PEACE plan: not utilised
• 79 year old woman admitted from home
• 1st admission: 16/09/12-08/11/12 (55 days)
with confusion/wondering. New diagnosis of
dementia. Discharged to NH with PEACE plan.
PEACE plan: not utilised
• 2nd admission: 13/12/12-21/12/12 (9 days)
with N&V secondary to constipation leading to
dehydration. Inappropriate admission.
• Son is not spoken to prior to arranging the
admission.
• RIP on 07/01/13 (17 days later)
Next steps
• Team work and communications are vital
• Clinical team identify patients at MDM
• Medical team have a key role in completing PEACE
medical information and discussing with patient or
representative
• Discharge coordinator and nursing team have key
role in communicating with nursing home and
supporting process
• Copy of PEACE should be sent with the patient to a
nursing home, to the GP and H@H team.
How we care for the dying is an indicator of how
we care for all sick and vulnerable people. It is a
measure of society as a whole and it is a litmus
test for health and social care services.
End of Life Care Strategy 2008.
Any questions or comments?
Dr E Mucci, Consultant Geriatrician, pager
849002 or extension 8181.
Dr Debbie Benson, Consultant in Palliative
Care, 01424755255
References
www.endoflifecareforadults.nhs.uk/
End of Life Care Strategy www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_086277
http://www.palliative-medicine.org/
http://www.ncpc.org.uk/National Council for Palliative Car
http://www.dyingmatters.org/gp
http://www.endoflifecare-intelligence.org.uk/home.aspx
http://www.dh.gov.uk/publications
Gomes B, Higginson IJ. Where people die (1974-2030). Past trends, future projections and
implications for care. Palliative Medicine 2008; 22: 33-41.
Office for National Statistics: www.ons.gov.uk/