Using early warning scores to widen access to end-of-life spiritual care

Introduction

Death is common in acute care settings: in 2018, approximately 45% of all deaths in England occurred in hospital. The National End of Life Care Strategy (Department of Health, 2008) sets out how health professionals should care for people approaching the end of life, their families and their carers. This is further underpinned by guidance from the National Institute for Health and Care Excellence (2015), which sets out how hospitals should deliver care to the dying adult in the last days of life.

Addressing spiritual needs

End-of-life care is not just about the physical aspects of caring; it must also include a psychological and emotional assessment of patients’ needs as well as an offering of spiritual care. This is an integral part of end-of-life care and should be addressed for all patients. The Leadership Alliance for the Care of Dying People (2014) identified five priorities when caring for someone who is dying; these are outlined in Box 1.

Measuring performance against national standards for end-of-life care is essential to enable hospitals to understand what they do well and where they need to make improvements. A retrospective national audit, using a clinical casenote review of a sample of all patients dying in hospital in May 2013, reported that documentation of discussions about spiritual needs were reported for only 21% of patients (Royal College of Physicians, 2015).

In a further audit of hospital clinical care relating to all adult deaths (RCP, 2016), discussion with patients during the last episode of care regarding their spiritual, cultural, religious or practical needs was documented in 15% of casenotes; in a further 27% of cases, there had been discussion with a person important to the patient. In 89% of cases, the identified needs were reported to have been met.

Improving end-of-life care services

Each hospital that participated in the RCP audits received a report of its performance against the national sample. Our trust, Mid Essex Hospital Services NHS Trust, employed nearly 5,000 staff and provided a comprehensive range of acute and community-based services from four sites. In the 2015 audit of adult deaths occurring at the trust, discussion with patients during the last episode of care regarding their spiritual, cultural, religious or practical needs was documented in 14% of casenotes; in a further 22% of cases, there had been discussion with a person important to the patient. Consequently, this was identified as an area for improvement.

Using the chaplaincy team to deliver training and education to clinical staff was the first consideration; however, freeing up staff to attend additional training proved challenging in a busy district hospital. It became evident that a more innovative way was needed to improve access to spiritual care. Proactively identifying patients who had a last-days-of-life care plan in place was considered as a way to improve unmet spiritual care needs.

The trust had been using the CareFlow Vitals e-observation system to record bedside clinical metrics for the previous five years. Initially the system was introduced across all 21 adult wards to identify the signs of a deteriorating patient. Nurses measure and input data to create an alert as part of an early warning system to trigger clinical interventions for the patient; these are defined by a pre-agreed trust protocol and national guidelines.

“Proactively identifying patients who had the last-days-of-life care plan in place was considered as a way to improve unmet spiritual care needs”

Identifying those at the end of life

The system was introduced to promote effective communication across the multidisciplinary team and provide efficient use of resources. Its aim was to identify the right person for the right patient at the right time. Part of the success of this system was the fact that it differentiated between those patients who needed active escalation and those who could be, potentially, at the end of their life; it ensured patients were on the care pathway that would meet their individual needs.

The software allowed an icon to be placed on the digital record of patients identified as ‘not for monitoring’ (Fig 1). Clinicians could then see which patients were not for vital-signs monitoring and the trigger-response team could use the icon to identify whether patients required review. In addition, the end-of-life care facilitator identified a further benefit: the icon served as an opportunity to improve care for patients at the end of life. By using the list of patients whose digital record featured the icon, it was possible to identify those who might wish to receive care from the pastoral and end-of-life team.

A programme of spiritual care interventions was established by the chaplaincy team and offered to those identified through use of the icon. Until this opportunity arose, the chaplaincy team depended on receiving referrals from patients, families, staff and others in the community.

Impact of the new system

In the year from April 2017 until March 2018, before we used the CareFlow Vitals icon, the records kept by the team showed 201 referrals to the chaplaincy team for patients at the end of life (or for their families). In April 2018, the team began to pilot the scheme using the CareFlow Vitals system to extend the reach of the pastoral care team and chaplaincy services.

From April 2018 until March 2019, the chaplaincy team provided spiritual care to 364 patients, an increase of 81% compared with the previous year. This increase was related to our use of the CareFlow Vitals icon (Table 1). Spiritual care was provided to 86 patients for whom the referral was attributed to use of the CareFlow Vitals icon. These cases comprised 24% of our end-of-life care caseload that year and 52% of the total increase.

The numbers cited relate to those patients identified using the CareFlow Vitals system who accepted spiritual care; as it does not include all those who were approached and asked if they wished to be referred to the chaplaincy team [n = 322], the impact of the new system is underreported in terms of patients being given the opportunity to receive spiritual care.

In 2018-2019, we identified 322 patients who were flagged as at the end of life using the CareFlow Vitals system; of these, 130 patients declined support and 86 accepted it; there was no response from the remainder of those approached (this is often because families do not respond to requests or staff do not report back).

There are a few notes of caution to our work. It is impossible to know whether patients at the end of life might have been referred to us by another means, even if not logged as CareFlow referrals. Some of the increase in caseload in 2018-2019 may have been the result of staffing changes to the chaplaincy team. There were some false positives in that some ‘not for monitoring’ patients were not in the last days of life but were for fast-track end-of-life discharge home.

Conclusion

Spiritual support is a recognised aspect of holistic care for people who are dying. We have described a locally developed innovative solution to improve the accessibility of end-of-life care at our trust. Implementation of this scheme has been hugely beneficial to identifying individuals dying in hospital; it has given more patients the chance to receive spiritual care and provided a consistent service across different clinical areas.