End of Life resources

Unfortunately due to the current outbreak we do need to update you on imperative procedures and support with regards to End of Life and Advance Care planning.

Electronic signature will be acceptable for DNACPR forms as an INTERIM measure during the COVID pandemic

  • EEAST (Ambulance Service) should accept electronic signatures for DNACPR
  • ENH CCG GPs have been asked to also send a paper copy of the DNACPR to the care home, or the patients home, so a hard copy is available in the patient’s records

 Please see comms below sent from East and North Herts CCG:

 Dear Colleagues,

 

 We have had written confirmation via email from Dr Tom Davis, Medical Director EEAST including the bulletin being sent to EEAST crews today (attached) that an electronic signature will be acceptable for DNACPR forms as an INTERIM measure during the COVID pandemic. These will be valid if completed remotely, and also valid if they are not completed on the EEAST template form (i.e. on an Ardens template). Crews are being reminded to check for Advanced Care Plans, Treatment Plans, DNACPR and ReSPECT forms.

 

 We must remember that our aim to ensure important conversations about treatment, interventions and dying have taken place AND are recorded so clinicians, carers, families have access to the best information to support decision-making at critical points in care and to ensure people know and understand this is important.

 

 The letter from Ruth May, Chief Nursing Officer for England of 7th April reminds us that:

 

 “The NHS Constitution is clear that we should deliver care and support in a way that achieves dignity and compassion for each and every person we serve. We should be cognisant of the principle of equity of access for those who could benefit from treatment escalation, and the principle of support for autonomy for those who want to be involved in decisions. Even under pressure we strive for the delivery of personalised care and high standards of patient experience.

 

In regard to those patients who are the most vulnerable, we should encourage them to discuss their individual wishes and concerns regarding their treatment preferences should they develop COVID-19 symptoms and record those preferences in an advance care plan.”

 https://www.england.nhs.uk/coronavirus/publication/maintaining-standards-pressurised-circumstances/

 

 This change is in response to the rapidly changing situation where Primary and Community Services are working virtually to protect ‘at risk’ patients. Please also continue to do a paper form and SEND it to the care home or patient’s home so a hard copy is available in their records, in particular if the plan is for the DNACPR decision will also apply after the pandemic period.

 

Kind Regards,

Dr Rachel Joyce

Herts and West Essex STP Clinical and Professional Director

East and North Hertfordshire CCG Medical Director &

Mark Andrews, CCG End of Life GP Lead

Please note the below applies to both older people and Adult Disability Services

If you are a Learning Disability Service provider, please make sure you are using supportive materials here. Please make sure you include your social care team where DNAR’s are being put in to place with completed best interest decisions.

1. Advance Care Planning and DNACPRs

Some provider organisations are concerned about pressure being exerted to ensure that all the people in their care have advanced care planning in place and blanket ‘do not resuscitate’ orders.

joint statement by the Care Provider Alliance, Care Quality Commission, the Royal College of General Practitioners and the British Medical Association makes it clear that advance care planning should be personalised and must not be applied to groups of people.

It’s very important that the wishes of people are respected, taking into account their capacity to make decisions, and unnecessary distress is avoided.

The Resuscitation Council has published some FAQs on ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) and a Quick Guide for Social Care is available from NICE.

Have you had Advance Care Planning discussions?
Talking to patients/residents and those close to them about prognosis, ceilings of treatment and possible end of life care is often challenging. These conversations, which constitute advance care planning, are useful during normal times, but even more so during the COVID-19 outbreak.

Conversations may become even more difficult, as health professionals may have to triage patients, often in emergency or urgent situations, and prioritise certain interventions and ceilings of treatment.

Please find below statement from CQC

Joint statement on advance care planning 

The importance of having a personalised care plan in place, especially for older people, people who are frail or have other serious conditions has never been more important than it is now during the Covid 19 Pandemic.

 

 

Where a person has capacity, as defined by the Mental Capacity Act, this advance care plan should always be discussed with them directly. Where a person lacks the capacity to engage with this process then it is reasonable to produce such a plan following best interest guidelines with the involvement of family members or other appropriate individuals.

Such advance care plans may result in the consideration and completion of a Do Not Attempt Resuscitation (DNAR) or ReSPECT form. It remains essential that these decisions are made on an individual basis. The General Practitioner continues to have a central role in the consideration, completion and signing of DNAR forms for people in community settings.

It is unacceptable for advance care plans, with or without DNAR form completion to be applied to groups of people of any description. These decisions must continue to be made on an individual basis according to need.

This is a joint statement from the following organisations:

British Medical Association (BMA)
Care Provider Alliance (CPA)
Care Quality Commission (CQC)
Royal College of General Practice (RCGP) 

Please see updates below on actions for EN Herts CCG Residential based providers

What do you need to do?

Dr Rachel Joyce, East and North Herts CCG Medical Director, asks you to do four simple things to ensure these conversations are recorded and shared. The CCG have also asked other health professionals, including our local GPs and hospices to support you in this.

  1. Please support advanced care conversations with all residents. The recent guidance from the British Geriatrics Society (BGS) states “Care homes should work with General Practitioners, and as appropriate community healthcare and hospice staff to review Advance Care Plans as a matter of urgency with care home residents. This should include discussions about how COVID-19 may cause residents to become critically unwell, and a clear decision about whether hospital admission would be considered in this circumstance.” Please see the infographics and guidance below for help in having these conversations. The guidance suggests a sensitive yet direct approach is most helpful, for example using questions such as, “If you were to become seriously unwell due to an infection such as coronavirus, where would you like to be cared for?” and “What things would be important if you became more seriously unwell and might die?”
  2. Please use the attached Treatment Escalation Plan to record these conversations accurately in their care records. Note that HCT and local hospices use a more clinical and detailed TEP, this is also valid, and you may use that to complete this form if one has been completed by other professionals for any of your residents.
    » Click here for TEP (Treatment Escalation Plan) Template

     

  3. If a resident does not have a DNACPR status recorded, or if you believe current ones need reviewing, please inform their GP by 17th April, who should review this part of their advanced care plan
  4. Please share the completed TEP with the resident’s GP and any other key health professionals; this will ensure key information is recorded in electronic patient records

Key Contacts for information and support:

  • Your GP (who will have access to advice and guidance from frailty consultants and palliative care consultants)
  • Hospice Support Lines (below)


Simple infographics and guidance to support conversations:

  • ACP in context – infographics for Care Homes – click here

     

  • Discussions about goals of care COVID-19 – click here

     

  • Guide to decisions around CPR

» DNACPR Patient Leaflet

If you are from a Herts Valley CCG residential provider

Ensure that ACP and DNRs are up to date for all residents and shared with GPs. If you need support with how to approach conversations and care planning then please contact your CHIT nurse (Care Home Improvement Nurse). Please ensure that that Advance Care Planning discussions are being held and updated asap for those already a resident and on admission for new residents.

» BGS Guidance

You will be aware, national guidance and direction to health and care services is constantly evolving and being updated, services are being reconfigured to adapt to the situation. Therefore, we will ensure you are kept updated if services change or guidance is updated

Resources from the ‘Advance care planning’ webinar

» Advance care planning- what does it mean? 13th May Webinar
» Advance care planning- what does it mean? 13th May Slides

Resources from the ‘Significant Conversations at End of Life’ webinar

» Significant Conversations at End of Life – 17th April Webinar
» Significant Conversations at End of Life – 17th April Slides
» Q&A’s – Significant Conversations at End of Life

2. EOL Support Lines

Herts Valley Providers
The Palliative Care Referral Centre provides advice as a 1st point of contact for palliative and end of life patients.

Call: 0333 234 0868
Monday to Friday 9am – 5pm
Saturday, Sunday and Bank Holidays 10am – 2pm
Specialist Palliative Care advice is available 24 hours a day – 020 3826 2377

East and North Herts Providers 
Provides support for service users and professionals to help avoid unnecessary or unwanted hospital admissions

  • Localities – Welwyn / Hatfield, Upper Lea Valley, Stort Valley and Villages, Lower Lea Valley

Call Isabel Hospice Advice Line: 01707 382500
9am to 5pm, Monday to Friday
Out of hours and weekends – 01707 382575

  • Localities- Stevenage, North Herts

Call: 01462 679540
Garden House Hospice Advice Line
24 hours a day 7 days a week

3. DNACPR Forms

Electronic signature will be acceptable for DNACPR forms as an INTERIM measure during the COVID pandemic

  • EEAST (Ambulance Service) should accept electronic signatures for DNACPR
  • ENH CCG GPs have been asked to also send a paper copy of the DNACPR to the care home, or the patients home, so a hard copy is available in the patient’s records

Please see comms below sent from East and North Herts CCG.

Dear Colleagues,

We have had written confirmation via email from Dr Tom Davis, Medical Director EEAST including the bulletin being sent to EEAST crews today (attached) that an electronic signature will be acceptable for DNACPR forms as an INTERIM measure during the COVID pandemic. These will be valid if completed remotely, and also valid if they are not completed on the EEAST template form (i.e. on an Ardens template). Crews are being reminded to check for Advanced Care Plans, Treatment Plans, DNACPR and ReSPECT forms.

We must remember that our aim to ensure important conversations about treatment, interventions and dying have taken place AND are recorded so clinicians, carers, families have access to the best information to support decision-making at critical points in care and to ensure people know and understand this is important.

The letter from Ruth May, Chief Nursing Officer for England of 7th April reminds us that:

“The NHS Constitution is clear that we should deliver care and support in a way that achieves dignity and compassion for each and every person we serve. We should be cognisant of the principle of equity of access for those who could benefit from treatment escalation, and the principle of support for autonomy for those who want to be involved in decisions. Even under pressure we strive for the delivery of personalised care and high standards of patient experience.

In regard to those patients who are the most vulnerable, we should encourage them to discuss their individual wishes and concerns regarding their treatment preferences should they develop COVID-19 symptoms and record those preferences in an advance care plan.”


https://www.england.nhs.uk/coronavirus/publication/maintaining-standards-pressurised-circumstances/

 

This change is in response to the rapidly changing situation where Primary and Community Services are working virtually to protect ‘at risk’ patients. Please also continue to do a paper form and SEND it to the care home or patient’s home so a hard copy is available in their records, in particular if the plan is for the DNACPR decision will also apply after the pandemic period.

Kind Regards

Dr Rachel Joyce

Herts and West Essex STP Clinical and Professional Director

East and North Hertfordshire CCG Medical Director

&

Mark Andrews

CCG End of Life GP Lead

4. Remote Verification of Death in Care Homes

Updated Guidance for Coronavirus (COVID-19): verification of death in times of emergency for Care Homes

Clarifying existing practice for verifying deaths outside of hospitals and providing a framework for safe verification of death during the Coronavirus emergency. Click here to view. Although this guidance refers to all care delivered in the community, this update only applies to Older People Care Homes in Hertfordshire. East & North Hertfordshire and Herts Valley have agreed their approach and support during this period.

What does it mean for your Care Home?

Where a death is expected, the GP/clinician can request for the verification to be done via video calling with the Care Homes support. The verification will be led by the GP/clinician on the video call. The Care Home staff do not need to be signed off as competent but do need to be familiar with the process and feel comfortable to support (Staff requirements – Senior Member of staff with good communication and experience of witnessing a deceased individual).  During core hours, the verification (remote or Face to Face) should be conducted by a clinician from the president’s own GP practice and out of hours by a clinician from the NHS111 *6.

Important: Remote verification is not the only option for verification and face-to-face verification will still take place if the GP/ Clinician does not want to complete via video call or the Care Home does not feel comfortable with a remote verification.

This guidance only applies to an expected death. An expected death is the result of acute or gradual deterioration in the resident’s health and often due to advanced disease and terminal illness. The coroner must be notified for any death that is unexplained, unnatural, violent or of an unknown cause. COVID-19 as a cause of death (or contributory cause) is not a reason on its own to refer a death to the coroner.

The process of death verification assumes that:

  • Resuscitation has already been ruled out
  • Identification of the presumed deceased can be verified
  • The presumed deceased is an adult
  • The clinician is able to ascertain the circumstances leading up to the death and relevant history
  • Privacy, dignity and cultural or religious circumstances are maintained
  • The clinician is satisfied that the death is expected (i.e. does not need to be referred to the coroner or police)

 

» Click here for a copy of the letter sent to Primary Care by the CCG’s

Resources from the ‘Remote Verification of Death’ webinar

» Remote Verification of Death – 28th May Webinar
» Remote Verification of Death – 28th May Slides

5. Verification of Death

How should we obtain a death certificate if we do not have access to a GP?

» Click here to view CQC FAQS

It’s important to note that there’s a difference between ‘confirmation that life is extinct’ and ‘certification of death’.

Confirmation that life is extinct is what is needed before a funeral director can remove a body from a care home.

You’ll find more details in our information for GPs:
Nigel’s surgery: Who can confirm death?

In summary, the law:

  • Does not require a doctor to confirm death has occurred or that “life is extinct”
  • Does not require a doctor to view the body of a deceased person
  • Does require the doctor who attended the deceased during the last illness to issue a certificate detailing the cause of death

If a death is expected, it’s recommended that staff in the care service discuss and agree arrangements with the GP in advance. This would mean that when death occurred, staff could contact the funeral director to arrange the removal of the body, and ensure that the GP with whom the person was registered was notified as soon as is practical. The GP could provide a death certificate later.

In the event of a sudden or unexpected death, although it is not a legal requirement, a visit by the GP with whom the patient was registered is recommended – to examine the body and confirm death. In the event of an unexpected death out of hours, it would be helpful if an out-of-hours GP were to attend, so the emergency services are not called when this could be avoided. The GP should then report the death to the coroner. This is usually done through the local police.

6. Death Notifications

For all providers please follow the below process for Death Notifications:

Older People Provider – Email CQC as normal and copy in See and Solve (seeandsolve.east@hertfordshire.gov.uk,
seeandsolve.west@hertfordshire.gov.uk) and assistance@hcpa.info

ADS and Mental Health providers – Email CQC as normal and copy in assistance@hcpa.info

If you are a Learning Disability Service provider please also notify LEDER – Click here

This information will be logged by the provider hub.

7. Guidance for Safe Handling for the Deceased

Some guidance has been designed to assist care staff who are required to manage the bodies of deceased persons who have had or been suspected of having COVID-19. This guidance has been developed to ensure that:

  • the bodies of those people who have died as a result of COVID-19 and the bereaved family of the deceased are treated with sensitivity, dignity and respect
  • people who work in these services and mourners are protected from infection

8. Chief Coroners Office Summary of the Coronavirus Act

The document linked below contains the essential things to know on MCCDs and cremation following implementation of relevant provisions in the Coronavirus Act 2020. This is the Chief Coroner’s Office’s assessment of the legislative position.

» Read the letter

9. EOL Resources and Education

DNACPR Easy Read [.PDF] Click here
“What If” Celebrating My Life [.PDF] Click here
Six steps to success in End of Life Care during COVID-19 Click here
Hospice of St Francis – Care Planning Guidance and Template [.PDF] Click here
Queens Nursing Institute – EOL Resources [.PDF] Click here
Hospice of St Francis Resources Click here
Talking to relatives [.JPG] Click here
Non-Injectable PRN [.PDF] Click here
British Geriatric Association Click here
Centre of Advanced Palliative Care resources Click here
Gold Standard Framework Click here
EOL E-Learning Resource- Royal College of General Practitioners Click here
Advance Care Planning Conversation videos- Guys and St Thomas Click here
Palliative & End of Life Care Click here
Anticipatory Meds for End of Life Care Click here
Uncertain Recovery Click here
Having The Conversation – Scenario Click here
Adults Sim Scenario: COVID-19 Click here
Teaching of the ReSPECT tool/ DNA-CPR discussion Click here
MDTea by the Hearing Aid Podcasts Click here
Podbean Podcasts Click here