Optimising end of life care with DaffodilsSimon Curtis - 18 Apr, 2019
Optimising end of life care for our dying patients has always been a high priority for primary care. It has simultaneously been one of the most rewarding and yet also challenging things that we do. When patients die an expected death in their own home, comfortable and pain free, surrounded by those that love them and with everyone prepared and understanding what is happening it is a success that lives long in the memories of those that are bereaved. And yet, although this may be the goal, things often seem to fail with last minute admissions, insufficient home care, lack of co-ordination or poor symptom control. How can we do better?
Improving end of life care has always been a Hot Topic, but it is now more so as it is a key part of the NHS Long Term Plan and central to this are the Ambitions for Palliative and End of life Care produced jointly by the NHS, the GMC, CQC and the royal medical colleges including the RCGP along with charitable partners. For GPs in England, it has become even more of a Hot Topic with end of life care being one of the two quality improvement domains in the new GP contract. This year to support this further for primary care teams, the Daffodil Standards have been published. This is an evidence based and structured approach developed by the RCGP and Marie Curie to help GP practices to offer the best end of life care for patients. For practices that sign up to the Daffodil standards (and they are free), they are recognised by the CQC and by the new NHSE GP contract as being a robust framework to provide evidence of quality of care.
The daffodil standards were discussed in an excellent BJGP editorial last year and were finally published earlier this Spring. As the BJGP paper points out, the pressures to provide optimal end of life care in the community are growing fast. It is estimated that the number of people needing palliative care will increase by 25% by 2040, with dementia and old age being the main drivers as well as cancer.
Traditionally palliative care has had a very medical model, focussing on control of biological symptoms. These new standards recognise that key to the success of end of life care requires much more than symptom control and syringe drivers. Whilst knowing how best to control pain, nausea, constipation, vomiting, hiccoughs etc is of course essential in reality palliative care often fails in the community because of psychosocial determinants such as loneliness, isolation, depression, anxiety and inability to manage. Early identification of dying patients, communication, and planning and delivering care that is personalised to the patient and in line with their wishes is of course key. But, to deliver this we will need the involvement and engagement of the whole primary care team and better collaborative working with outside agencies including the development of health and social partnerships with the voluntary sector and also the communities in which we work.
In many ways, the daffodil standards can be seen to de-medicalize palliative care and to broaden the agenda of care and in this respect they are very much in line with current themes of primary care such as working in partnerships, personalised care, advance care planning, social prescribing and psycho-social support as well as traditional medical and nursing care. Providing optimal end of life care is a huge responsibility, but it is not one that we should burden on our own and it is to be welcomed that these new guidelines recognise that.