New approach to end of life conversation and documentation training

The role of end of life care facilitator was funded for one year via an ‘Enabling Choices Grant’ from St James’ Place Foundation/Hospice UK.

The primary aim of this one-year post was to facilitate end of life conversations and documentation.

Workshops were provided across three acute hospital sites and took on a different form to the usual training format of standing at the front running through a powerpoint presentation.

Attendees included a wide range of staff – nurses, theatre and day surgery staff, occupational therapists, physiotherapists, physicians, healthcare assistants and therapy assistants.

The groups with the widest range of professions present were great for helping everyone to see that they all feel similarly when it comes to the issues around end of life conversations and documentation, and that everyone has a role to play, no matter what their profession or grade.

Based on the methods used in Brief Solution Focused Therapy(1), I created workshops that would enable participants to share their knowledge of elements of end of life conversations such as:

• advance care planning
• do not resuscitate orders
• advance decision to refuse treatment
• preferred place of care/death.

In doing this we were able to focus on the crucial conversations around these elements of end of life care with participants putting themselves in the position of a patient and what they would want from a ‘perfect’ advance care plan.

After creating a vision of the ideal advance care plan, participants were asked to think about the next steps. Common answers included:

• Improved communication – both interdisciplinary and with patients/family in out-patients and in the community, not just in the acute setting.
• Better IT to share preferred place of care/death and do not resuscitate with all settings and ambulance service.
• Advanced communication and advance care planning training for all staff.
• Individual professions to take ownership of their role in advance care planning.
• Staff to have time to reflect and give/receive feedback.

Then the participants were asked to think about what small step they could make toward the perfect advance care plan.

Improved confidence

A questionnaire asked the participants to rate from 1-10 their confidence in certain areas of end of life conversations and documentation, before and after the session.

An increase in confidence was seen across all of the questions after the workshops, with the biggest increase seen in the confidence to document conversations.

One participant identified the need for a ‘toolkit’ of helpful phrases, which I developed after this request. As well as conversation starters, this included examples of how to handle difficult conversations and questions. The idea was to help people to see that questions can be indicative of wider concerns and if you are unable to exactly answer a patient’s question (eg ‘Am I dying?’) you can still listen to what people are worried about and possibly help them with the areas that are within your role or experience.

The person who requested the toolkit fed-back: “I lead my first DNAR [do not attempt resuscitation] conversation independently with a patient last week and the phrases were useful to start the conversation – I know in the past I would have found this very daunting but the conversations have helped me think about how to start off these conversations.”

Another participant feedback that: “the workshop helped me increase my confidence when helping the family of an end of life patient. It enabled me to understand the need for more information for the family.”

These are illustrative of the power of this form of workshop, whereby participants feel more confident to engage in end of life conversations as they have been empowered to take a small step toward the ideal future of the ideal advance care plan.

The group is able to share their experiences, both good and bad, but the facilitator will always focus on the good practice rather than the ‘failed discharge’.

In doing so, good practice is shared while acknowledging that sometimes, no matter how hard we try, a situation will not work out the way you or the patient want it to.

For this reason, I also feel this form of training could contribute to a reduction in staff burnout, benefiting staff and healthcare as a whole.

A full report will be published in June 2015 and will be available from the Pilgrims Hospices website.

1. In more traditional psychotherapeutic approaches practitioners assume it is necessary to make an extensive analysis of the history and cause of their clients’ problems before attempting to develop a solution. Solution-focused therapists recognise that causes of problems may be extremely complex, but that their solutions do not necessarily need to be. Solution focused therapists believe personal change is already constant and that people can be helped to identify positive directions for change in their life by co-constructing with their clients a concrete vision of a preferred future for themselves.