Challenges to implementing/sustaining end of life care in practice
This section will identify a range of generic challenges that may be encountered along with some suggested strategies/tips to help overcome these.
Within the actual content headings of the guide some additional specific challenges relating to that particular area will also be identified.
Implementing any initiative or change is a complicated process, and there are often a range of barriers to be overcome. Take advice from senior colleagues in your area who have led initiatives and ask them to share strategies and approaches which helped make the process less arduous. Concentrate your initial efforts on areas/wards/practices who have expressed an interest in the initiative and who have staff willing to work with you. You may find that this will generate interest from other people who were initially less receptive.
It is important to set up a contact network with other facilitators/leads working in other areas. This will provide an opportunity to share helpful hints and support each other.
Potential challenges and suggested strategies
Competing priorities from National and Local Health and Social Care Agenda:
- Ensure senior staff in health and social care organisations remain informed of End of life care activity both locally and nationally
- Utilise available resources/reports/events on this site
- Nominate lead person in each organisation to disseminate reports or other information
Lack of awareness about end of life care work:
- Send out fliers/information to local teams/departments or organise an information event.
- Engage with local education providers to ensure that end of life care is incorporated into existing education programmes for those involved in care delivery
- Request an opportunity to do a brief overview at any existing forums/groups/meetings
- Set up local forums/steering group with input from all relevant stakeholders to allow sharing of information
- Contact other local/national education providers who have expressed a willingness to share ideas/resources and consider joint regional approach
- Engage with long term conditions groups and patient/carer/user forums
Staff shortages:
- Discuss with other teams how they have managed to overcome issues such as staff shortage
- Join with other staff in your locality to formulate joint working initiatives
- Liaise with local training department to explore possibilities
- Report to management if there is a genuine capacity issue which prevents delivery of End of Life care work
- Establish link person in each area
Teams too busy:
- Flexibility eg arrange brief meetings at staff handover times and negotiate most appropriate approach and time for that area
- Consider arranging meetings in evenings and weekends when some areas feel less pressured
- Utilise any contact as a learning opportunity
- Ensure staff awareness that provision of quality End of Life Care is a key recommendation of many National Service Frameworks, NICE guidance and Our NHS, our future, and not an optional extra.
Lack of finance to appoint facilitator/lead, to backfill staff or to purchase equipment:
- Liaise with managers or commissioners to explore if there are any slippage funds
- Demonstrate cost savings of reducing admissions or length of stay in hospital
- Work with commissioners/team to incorporate end of life care into Local delivery plans
- Look at existing access to equipment, is there an opportunity to pool, share or borrow from equipment stores?
- Explore potential opportunities for joint arrangement between health, social care and voluntary independent sector to contribute eg to purchasing equipment/making a bid for staff
- See Commissioning examples in case studies.
Uncertainty about prognosis or criteria for putting patients on a palliative care register:
- Encourage practitioners to discuss with team members and consider drawing up local guidance
- Signpost to GSF Prognostic Indicator Guidance and use of the surprise question
- Arrange formal/informal education sessions
Difficulty diagnosing dying:
- Acknowledge that this may be difficult in some instances
- Use of Liverpool Care Pathway
- Use of educational resource, example in the Learning Organisations section
- Encourage staff to discuss deaths of people not on pathway and identify indicators
Complex ethical issues, eg DNAR, Hydration/nutrition, Mental Capacity Act:
- Refer to local policy guidance and seek clarification, refer to ethics department
- Use reflective practice/significant event analysis to review difficult cases
- Utilise ethical framework to assist in decision making and record accurately in record/notes
Practitioners may not have received communication skills training and unable to initiate sensitive discussion:
- Education guide for practice, examples in the Learning Organisations section
- Monitor current provision of communication skills training for Medical/nursing and other care staff
- Liaise with education providers to extend training/education to generic staff
Societal Taboo around death and dying:
- Continue to ensure that end of life care remains in high profile
- Utilise local media to advertise events
- Arrange information sessions for voluntary and carer groups
- Present to patient/user forums
- Place information leaflets in public places eg libraries, GP surgeries
Lack of partnership working:
- Explore opportunities to place End of Life Care on existing joint working groups
- Awareness raising in different forums
- Organise whole systems event
- Extend invitations to all planned events to a range of stakeholders including non statutory sector
- Acknowledge value the contribution from all Our Health, Our Care, Our Say
- Map out end of life care pathway with clearly identified benefits of joint working
Out of Hours difficulties:
- Engage with PCT Out of Hours steering group
- Make contact with all agencies providing out of hour services and keep them informed about all end of life activity/initiatives
- Ensure opportunity for out of hours providers to access relevant education sessions
- Implement systems to enhance communication eg handover forms/systems to highlight patients who are on palliative registers or have advance care plans
- Liaise with primary care organisations/pharmacists to ensure availability of medicines out of hours, share details of initiatives such as OOH drugs boxes
NHS Reforms and Changes such as Introduction of Practice Based Commissioning and Payment by Results:
- This can actually be an opportunity to engage with commissioners to demonstrate the benefits of avoiding unnecessary admissions/reducing length of hospital stay.
- Liaise with local health leads to submit joint bids/ business cases for service delivery
- Work with/advise practice based commissioners of benefits and enhanced care delivery when proactive management strategies are implemented
- Work with colleagues including patient groups to map out a patient care pathway
- Find out if there are any opportunities to develop personal skills in drawing up business proposals and increasing awareness of financial issues
- Keep updated about these reforms by reading current documents
