No one dies unassessed: comfort documentation in the last days of life on a dedicated end-of-life ward versus matched wards
Abstract
Introduction
NICE NG31 requires regular, documented assessment of symptoms in the last days of life, yet dying patients on acute wards frequently go unassessed. We audited last-days-of-life (LDOL) flowsheet documentation on a newly opened nurse-led end-of-life care ward against matched deaths on acute wards.
Methods
The first 50 consecutive ward deaths were matched to 50 acute ward deaths (exact specialty; age within ten years; nearest length of stay). Electronic flowsheet entries for the final 72 hours of life were extracted for all comfort domains (pain, agitation, respiratory symptoms, mouth care and others), and compared against trust audit standards. Observation intensity was compared using paired Wilcoxon tests.
Results
An individualised care plan was in place for 100% of ward patients (target 95%). Each comfort domain was documented in 98–100% of ward patients versus 65–67% of matched controls. Observation intensity was higher (median 9.7 versus 8.7 entries per domain per 24 hours; p=0.042). No ward patient went through their final 24 hours without an agitation or respiratory assessment, versus 29% of controls. Identified uncontrolled pain was acted on within four hours in 64% versus 26%. Honest gaps remain: pain reviewed in the final six hours in only 60% (target 80%), a named lead clinician documented in 40%, and prognosis discussion documented in 56%.
Conclusions
A ward-level model built around comfort observation eliminated unassessed dying and doubled the rate of acted-upon symptoms. Residual gaps are driving an electronic documentation redesign and re-audit at six months.
Comments
management of EoL care in acute ward vs Eol Inpatient unit
I think this is very important work. I have worked on both an acute geriatric ward and in our hospital's End of life (EoL) inpatient unit (Ty Olwen) and I have felt that there is much more attention to comfort care provided in our EoL inpatient unit than on the acute wards as nurses and doctors are much more focused on following the SEWS chart regularly and reviewing dying patients much more regularly than on the acute ward and also ensure PRNs are given to ensure patient's are not distressed in the last few hours or days. It would be interesting to do a similar audit in our hospital to see if data would show objective difference in care provided by the acute geriatric ward vs the EoL inpatient unit.
Thank you, and happy to share the audit method
Thank you, and it is good to hear that your experience across an acute geriatric ward and Ty Olwen matches what we found. Your point about the rhythm of observation is exactly the mechanism we think explains the difference: on the dedicated ward the comfort observations are the ward's core work, so they happen on a schedule and the PRN response follows, whereas on an acute ward they compete with everything else. The audit is straightforward to repeat elsewhere: fifty consecutive deaths on the end of life unit matched to fifty acute ward deaths on specialty, age and length of stay, then extract the flowsheet entries for the final 72 hours for each comfort domain. I would be glad to share our data dictionary and extraction approach if you decide to run it; please do get in touch, and I would be interested to see how Ty Olwen compares.