Improving serious illness conversations and shared decision-making for paramedics



Project leads: Dr Nikki Pease, Consultant in Palliative Medicine and Mr Ed O’Brian, End of Life Care Lead, Welsh Ambulance Service


Participants: Dr Jo Hayes, Dr Ed Presswood


Velindre NHS Trust and Welsh Ambulance Services NHS Trust


This Bevan Exemplar project trained ambulance clinicians in end of life conversations to enable shared decision making.


Background


Patients and relatives are frequently dissatisfied about communication at the end of life (The 2015 Parliamentary Ombudsman report on death and dying). At the heart of this dissatisfaction is a lack of information, such that patients and relatives are ill-informed regarding expectation and choice at the end of life. This mismatch in expectation often results in the ambulance service being called.


Aims


This project aims to improve end-of-life care and communication by providing training on three main aspects:

  1. Serious illness conversation/communication skills.

  2. Symptom control at the end of life (which includes recognition that a patient is likely to be at the end of life) and administration of medications to improve symptom control.

  3. ‘Shared decision making’, whereby an experienced physician (usually from primary care or palliative medicine) would provide telephone advice/support to paramedics at the patient’s home.

In excess of 500 ambulance staff received face-to-face training. The project had an ‘all-Wales’ remit and sought to deliver consistent, evidence-based practice across the nation.


Ambulance clinicians were trained according to the same syllabus and by a core group of trainers with support from local palliative care teams, to ensure that there will ultimately be continued local ownership.


Challenges


Challenges identified and where possible, addressed during the project included:

  • Attendance issues: the team liaised with Swansea University to teach paramedic degree students in larger groups within a classroom setting.

  • Maintaining skills: the team produced a bespoke, free interactive eLearning programme to include topics similar to the face-to-face sessions including communication skills, end of life care and symptom control. Since the eLearning launch in early 2018, 443 ambulance staff have accessed the modules, and 296 have completed the 5-module programme. [https://wast.onclick.co.uk/]

  • Scaling up: To better achieve an all-Wales remit the Paramedic ‘Serious Illness Conversation Card’ was produced and issues to all Paramedics in Wales.


Outcomes


The key outcomes of the project have been:


  • There is evidence of significant changes to practice:

  1. 16% reduction in patients conveyed to the emergency department and therefore remaining at home.

  2. 30% increase in shared decision making (usually between paramedic and GP/ Palliative Medicine Physician).

  3. 8% increase in End of life medicines being administered by paramedics

  • Improvements in ambulance staff confidence in communication at the end of life.

Graph 1: Ambulance staff self-assessment of confidence in breaking bad news pre- and post-teaching - n= 649 pre teaching and 632 post teaching


Graph 2: Ambulance staff self-assessment of confidence in discussing advance care planning pre and post teaching - n= 326 pre teaching and 313 post teaching



The overall outcome is hoped to be Improved patient choice, improved support for family members and therefore their bereavement; better symptom control and ultimately a ‘good death’.


Next steps


The project and programme of teaching continues with teaching dates set for 2019. The project team has become involved in Future Care Planning projects throughout Wales to ensure ‘joined up’ working across care sectors, to ensure future care planning starts earlier in a patient’s journey and that a patient’s choices are transferred to the community setting, e.g. use of ‘message in a bottle’. The project and its results have also been shared in a peer-reviewed journal, and the team is also working to ensure UK Ambulance Services Clinical Practice Guidelines are amended to include information on ‘Shared decision making and medication at the end of life’.


Within a supportive environment we were given an excellent opportunity to learn more, to create and ultimately raise the profile of our project.
Nikki Pease




Part of cohort Bevan Exemplar Projects 2017-18