End of Life Care Audit and Quality Improvement Project in an Elderly Care Unit: Adherence to West Midlands Palliative Care Guidelines

Introduction

High quality end of life (EOL) care is essential to ensure comfort, dignity, effective symptom control, and care aligned with patient wishes. The West Midlands Palliative Care guidelines emphasise early recognition of dying, anticipatory prescribing, communication with patients and families, deprescribing non-essential medications, and individualised care planning. Delayed recognition of dying and inconsistent documentation may negatively affect patient-centred care. `To evaluate whether EOL care within an elderly care unit was delivered in accordance with West Midlands Palliative Care guidance and identify areas for quality improvement.

Methods

A retrospective audit of 30 inpatients recognised as being at end of life was conducted. Data collected included comfort observations, anticipatory medications, syringe driver use, palliative care team review, family communication, ReSPECT/TEAL documentation, medication optimisation, patient wishes, place of death, timing of EOL recognition, and interval from EOL decision to death.

Results

Compliance with anticipatory prescribing, family communication, and TEAL/ReSPECT documentation was 100%. Comfort observations were initiated in 83% of patients, palliative care review occurred in 77%, and medication optimisation was documented in 63%. Patient wishes or preferred place of care were documented in only 47% of cases. Fifty percent of patients required syringe drivers. Most patients died in hospital despite some expressing preference for home or hospice care. Delays in recognising dying were commonly associated with ongoing active management of potentially reversible conditions including infection, AKI, and respiratory failure. Many patients died within a few days of EOL recognition, suggesting possible late identification of the dying phase.

Conclusion

This audit demonstrated strong performance in communication and anticipatory prescribing but identified important gaps in documentation of patient wishes, medication rationalisation, and timely recognition of dying. A quality improvement project has been initiated involving an EOL checklist, staff education, and ward based reminders, with re-audit planned to assess improvement in compliance with guideline based EOL care.