Recognising patients at risk of deterioration and dying

Recognising patients at risk of deterioration and dying

An article written by Dr David Marco Research Fellow, Centre for Palliative Care, St Vincent’s Hospital Melbourne.

Care provider ability to recognising when a person is at risk of deteriorating or dying is an important component of the strengthened Aged Care Quality Standards and an ‘essential element’ of the National Consensus Statement on end-of-life care just released by the Australian Commission on Safety and Quality in Health Care. Yet recognising end of life is challenging. Dr David Marco describes the findings of a research study into nurses’ use of one prognostic tool – SPICT – on general medicine wards.

Why was it important for your team to do this research?

Recognising when a patient is at risk of deteriorating and dying is complex and inherently uncertain, even for seasoned clinicians. A recent national audit showed >70% of patients were recognised to be dying, but this occurred on average only one day before death. In addition, 66% of patients received potentially non-beneficial and invasive medical procedures within their last 48 hours of life. These findings are reflected internationally, demonstrating wide-spread challenges in the management of this vulnerable population.

In the last decade, research has focused on developing algorithms and screening tools devoted to identifying these people in our healthcare system. While tools have shown to accurately predict the risk of death in the next 6-12 months, most have yet to be incorporated into routine care. Common barriers affecting uptake relate to the clinical acceptability of these tools, pointing specifically to the absence of clinician judgement in the process, lack of guidance on appropriate clinical responses, and lack of sensitivity to individual and environmental circumstances.

The Supportive and Palliative Care Indicators Tool (SPICT) helps multidisciplinary teams identify patients at risk of deteriorating and dying in all care settings by highlighting potential palliative and supportive care needs. In combination with the Surprise Question, it is a relatively simple screen nurses can administer at the bedside or during handover.

 

What did you find out? Did any of the findings surprise you?

Our nursing team trialled this approach to 43 patients admitted to a general medical unit in a 24hr period. It was found that 70% of patients presented with either deteriorating and/or poor performance status. Most patients (72%) were dependent on family members on aspects of daily living, half (56%) presented with persistent symptoms, and 33% carers reported needing help and support.

93% of patients were classified as SPICT positive (e.g. in need of palliative and/or supportive care), of whom 40% died within 12 months. In response to the Surprise Question, medical registrars indicated that they would not be surprised if 55% of the SPICT positive cohort died within one year. Of all decedents, only one patient was known to the hospital-based palliative care service at the time of assessment.

 

What do you see as the major implications of the study for the wider aged care workforce?

While clinicians demonstrated some level of recognition of deterioration and dying, they were likely not confident in their prediction or how to respond. Many statistical prognostication models incorporate input-output ‘black box’ approaches which can inadvertently deskill our workforce and decrease confidence in the care of this population.

To be acceptable, models need to compliment clinical decision-making and provide a suitable clinical response piece, co-designed with the local workforce.

 

Research has the potential to have a positive impact on individuals and societies. What do you hope the impact of this research will be?

In addition to identifying patients at risk of deteriorating and dying, harnessing tools such as the SPICT can also assist in unpacking areas of unmet need which clinical teams can proactively respond to.

Importantly, the use of the SPICT in this context has shown to increase health professionals’ confidence in identifying and responding to patients approaching end of life. These tools can also promote preliminary dialogue between clinicians, patients, and families regarding the benefits of treatment, changing goals of care, and palliative care referral, if appropriate.


Author


Dr David Marco

Research Fellow

Centre for Palliative Care, St Vincent’s Hospital Melbourne


 

Reference

  1. Marco DJ, Whelan T, Bryan T, Weil JL. Recognising patients at risk of deterioration and dying on general medicine wards: a nurse-led point prevalence study. Aust J Adv Nurs. 2022 Dec 1;40(1):41-5.
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The views and opinions expressed in Palliative Perspectives are those of the authors and are not necessarily supported by CareSearch, Flinders University and/or the Australian Government Department of Health and Aged Care.