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19 October 2018

Royal College of Physicians report highlights UH Bristol poor prognosis letter

Palliative care and support team

The poor prognosis letter (PPL), developed by the palliative medicine team at the Bristol Haematology and Oncology Centre, is featured in the Royal College of Physicians report 'Talking About Dying' which has been released today.

This electronic letter, which takes just five minutes for clinicians to complete, is sent to a person's GP if after careful assessment it is believed they are likely to be in the last year of their life.

It tells the GP what conversations have already been had in hospital, so they can support them going forward, as well as any practical care which is needed going forward.

Miranda Flory, consultant in supportive and palliative medicine, explains:

"In 2013 our local GPs told us that they needed prognostic information from hospital specialists to help them identify people approaching the last year of life. The focus was about recognising which people might be in their last year, and so may benefit from additional support, and the opportunity to express their preferences about their care.

"We asked our medical colleagues to develop disease-specific indicators that a person may have a poor prognosis.  We then asked IT colleagues to design the PPL within our existing Integrated Clinical Environment (ICE) computer system.

"When we consulted with people in a focus group they told us that they were glad that professionals were communicating with each other for their benefit."

Around 30 to 60 PPLs are now generated each month, and have acted as a prompt for GPs to have more conversation about patients' future care.

One of the things GPs may discuss is where people would prefer to die, as many people would prefer to be at home if possible.

Looking at a group of patients who had a PPL completed between April and October 2015, only 36% died in hospital, which is lower than the proportion of the whole Bristol region at the time, which was 46%.

Miranda added:

"This project required a culture change, but using ward doctors as 'champions' helped the process to become everyday practice.

"It's meant that both GPs and hospital doctors understand what conversations have happened. This has confirmed the importance of helping people to talk about the future and their wishes and preferences."

The PPL has since been adopted nationally for patients with liver disease who may be in the last year of their life, and elsewhere in the UK.

The team have developed a new advance care planning clinic, which helps people to talk about and plan for their future.