The Preferred Place of Care Plan and why it was developed

The NHS Cancer Plan (DoH 2000) acknowledged that support for patients living at home with advanced cancer is sometimes poorly coordinated and may not be available 24 hours a day. Moreover, it acknowledged that cancer patients should be able to live and die in the place of their choice wherever possible.

Figures for the years 1996 to 1999 (ONS, 2002) showed that in Lancashire and South Cumbria there has been no shift in the number of hospital deaths as compared to deaths at home or in hospices. Approximately 25 per cent of people in the region die at home, which contrasts to approximately 50 per cent of terminally ill patients whose wish it is to die in their home (Dunlop et al., 1998; Townsend et al., 1990). This highlighted the huge need within our Network to address this issue and we attempted to do this through the development of the Preferred Place of Care document.

The Preferred Place of Care Plan (PPC)

The PPC is intended to be a patient-held record that will follow the patient through their path of care into the variety of differing health and social care settings. Guidance reference sheets for both the patient and carer and staff are available explaining the use of the PPC. The document provides an opportunity to record

• A family profile and carers needs
• The patients thoughts about their care, their choices and preferences
• The services that are available in a locality and being accessed by the patient
• Changes in care needs

PPC - A Nationally Recognised Tool for Palliative Care

The PPC originated from the Palliative Care Education Programme to evaluate the effectiveness of teaching on place of death (Cancer Plan 2000). It is now a nationally recognised tool for all palliative care patients as recommended in:

• The NICE Guidance on Supportive and Palliative Care for Adults with Cancer : March 2004
• Building on the Best : End of Life Initiative : July 2004

Building on the Best suggested that the success of the initiative reaching non-cancer patients will depend on increasing the use of the Liverpool Care Pathway, Gold Standards Framework and the PPC in District General Hospitals, Primary Care and Care Homes resulting in

• Greater choice for patients in where they wish to live and die
• Decrease in number of emergency admissions of patients who wish to die at home
• Decrease in the number of older people transferred from a care home to a DGH in the last week of life

By putting the patient and carer at the centre of the PPC, it is hoped that autonomy and control are fostered—factors that many patients perceive as being taken away from them during the terminal stages of disease. By capturing such detail it is also hoped that the PPC will provide data on what happens to patients who expressed a wish to die at home at the outset, and then died in a hospital or hospice setting. Was this patient choice or Hobson’s Choice? Did an on-call GP visit that did not know the patient and admit them to a hospice/hospital? Was it because the carer felt vulnerable and could no longer continue without more support?

Copies of the PPC are available for Health Professionals

The Preferred Place of Care Plan is now available in a PDF format. If you wish to receive a PDF version please email the Cancer Network via christine.wood@lsccn.nhs.uk

A supporting poster and leaflet have also been developed to advertise the Preferred Place of Care Plan to NHS patients and carers. It will allow patients and carers to gain more information about the PPC from a variety of possible sources eg GP, Clinic District Nurses, which in turn will assist community district nurses in notifying patients of the existence of the PPC. Click to download a copy of the poster and leaflet.

Initiating and using the PPC

At the outset of the development of the PPC we intended that this document is used as a patient held record and will, therefore, follow the patient into differing care settings. To this end we suggest that local services should identify the appropriate staff to initiate the PPC; our view is that the health care professional who has the greatest input and knows the patient should be the person to initiate the PPC whether that is in the community, a hospital, care home or hospice. The important thing is that practitioners have the appropriate communication skills and knowledge to undertake this activity.

The original criteria for initiating a PPC were if patients:

• Claim benefit under special rules- DS 1500
• Have input from a specialist palliative care nurse
• Are in advanced or terminal stages of the disease

However it may be that there are other criteria that can be applied to meet client needs in a locality.

Use of data

On the death of the patient, we are encouraging the outcome of the patient’s wishes to be discussed within the Primary Health Care team and their comments appended to the PPC.

Also, on the death of the patient the document is returned to one central point within the Cancer Network. At this point the data has been anonymised except for Gender, DOB and GP and it is then entered into a database and analysed, identifying any resource implications for caring for patients within the home setting.

What is currently in place

The PPC is currently embedded in practice in two Primary Care Trusts and is gradually being introduced into acute settings and care homes within one large Health Economy in the Network, before it is rolled-out across the Network.

To support the introduction of the PPC we are:

• Providing advanced communication skills training for use of the PPC for District Nurses across a Health Economy of approximately 250,000;
• Promoting its use with all GP practices within the selected Health Economy through general educational evenings/seminars and one to one visits to practices;
• Continuing to work with the ambulance service with further educational events being planned
• Holding educational events within Hospices;
• Developing the education of staff within the Acute Trust, which is paramount if the use of this document is to be sustained. We are looking to work with the Education Department within two Acute Trusts to run appropriate sessions, initially targeting specialist nurses in cancer care, wards where cancer patients are predominantly cared for, and then onto the wider remit of all care settings;
• Identifying and meeting the educational needs of staff within Care Homes.

• Hobson's Choice article

An article has been published in the International Journal of Palliative Nursing, 2003, Vol 9, No 10 Page 439

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