Digitally Recording Comfort Observations in the Last Days of Life.

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3 months have been on e-comfort obs, with 2/3 of all deaths in the first 12 months on e-comfort obs. The average length of time on e-comfort obs is 4 days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

What can you learn as a foundation doctor from analysing deaths in hospital?

Deaths in hospital represent a vital learning opportunity for both individual clinicians and the wider healthcare system. Many deaths are reviewed and discussed in morbidity and mortality meetings, with the Royal College of Physicians promoting Structured Judgement Review (SJR) methodology to support this discussion. An analysis of 1 year of SJRs in one hospital was undertaken, generating a toolkit to support junior doctors in evaluating in-hospital deaths. Here, the opportunities and limitations of this analysis are discussed, with consideration of ways to improve the uptake of SJR across the hospital team. These reviews exemplify one way of maximising learning from in-hospital deaths.

From COVID-19 to Green Recovery with natural capital accounting.

The COVID-19 pandemic and related social and economic emergencies induced massive public spending and increased global debt. Economic recovery is now an opportunity to rebuild natural capital alongside financial, physical, social and human capital, for long-term societal benefit. Yet, current decision-making is dominated by economic imperatives and information systems that do not consider society's dependence on natural capital and the ecosystem services it provides. New international standards for natural capital accounting (NCA) are now available to integrate environmental information into government decision-making. By revealing the effects of policies that influence natural capital, NCA supports identification, implementation and monitoring of Green Recovery pathways, including where environment and economy are most positively interlinked.

Seeking Excellence in End of Life Care (SEE Care): A Multi-Centered Acute Hospitals Service Evaluation.

CONTEXT: A proportion of UK hospital inpatients have palliative care needs but do not access specialist services. OBJECTIVES: To contemporaneously evaluate the significance of unmet specialist palliative care needs within the hospital inpatient population. METHODS: Prospective multi-centered service evaluation was conducted through 4 snapshots across 4 acute NHS hospital trusts. All patients identified as dying in each hospital were included. Data extraction included symptom burden, medications and completion of care plans. RESULTS: End-of-life care plans were completed for 73%, symptom-focused prescribing present in 96%. Symptoms were not well managed for 22%, with 4% suffering moderate to severely. Specific intervention was triggered in 56% of patients, consisting of prescribing advice and holistic support. CONCLUSION: There are significant unmet specialist palliative care needs within the hospital inpatient population. Contemporaneous data collection coupled with an outreach approach helps palliative care services better understand the experiences of dying people, alongside where improvement is needed.

Emotional intelligence in palliative medical education.

The death of a patient is one of the most stressful situations a healthcare professional can face for the first time at work or during training. Palliative and end of life care education aims to impart appropriate awareness and understanding of key issues arising at the end of life, but also to develop learners' interpersonal skills in leadership, communication and management of their own emotional load. There is a pressing need to be explicit around death, dying and care at the end of life and to equip clinical staff with the ability to manage the emotions that are experienced by their patients, their teams and themselves. Emotional intelligence is considered as a framework for medical educators to use in this setting with presentation of a simulated patient vignette to contextualise this.

Care of the dying person before and during the COVID-19 pandemic: A quality improvement project.

The current COVID-19 pandemic has necessitated the redeployment of NHS staff to acute-facing specialties, meaning that care of dying people is being provided by those who may not have much experience in this area. This report details how a plan, do, study, act (PDSA) approach was taken to implementing improved, standardised multidisciplinary documentation of individualised care and review for people who are in the last hours or days of life, both before and during the COVID-19 pandemic. The documentation and training produced is subject to ongoing review via the specialist palliative care team's continuously updated hospital deaths dashboard, which evaluates the care of patients who have died in the trust. We hope that sharing the experiences and outcomes of this process will help other trusts to develop their own pathways and improve the care of dying people through this difficult time and beyond.

Natural capital accounting for better policy.

A growing number of countries is setting up natural capital accounts (NCA) based on the system of environmental-economic accounting (SEEA); however, actually using them for better policy making turns out to be complex. This paper synthesises lessons on the institutional mainstreaming of the SEEA and its use in improving policy decisions affecting natural capital. It draws on discussions held at two Policy Forums organised by the World Bank Wealth Accounting and Valuation of Ecosystem Services program and the United Nations Statistical Division. Practical examples of how the SEEA helps to improve policy making are explored. Emerging from the Forums were ten principles for making NCA fit for policy. These principles promote a comprehensive NCA organisation, a purposeful use of accounts, trustworthy methods and institutionalisation of NCA mechanisms in government. To put these principles into practice, six strategies are outlined: (1) assure credibility of the accounts; (2) align supply and demand for NCA; (3) assure high level support for NCA; (4) encourage cooperation between institutions so NCA and policy are mutually constructive; (5) provide evidence that natural capital is economically important and; (6) assure policy-relevant communication of NCA results.

A chimeric tetravalent dengue DNA vaccine elicits neutralizing antibody to all four virus serotypes in rhesus macaques.

DNA shuffling and screening technologies were used to produce chimeric DNA constructs expressing antigens that shared epitopes from all four dengue serotypes. Three shuffled constructs (sA, sB and sC) were evaluated in the rhesus macaque model. Constructs sA and sC expressed pre-membrane and envelope genes, whereas construct sB expressed only the ectodomain of envelope protein. Five of six, and four of six animals vaccinated with sA and sC, respectively, developed antibodies that neutralized all 4 dengue serotypes in vitro. Four of six animals vaccinated with construct sB developed neutralizing antibodies against 3 serotypes (den-1, -2 and -3). When challenged with live dengue-1 or dengue-2 virus, partial protection against dengue-1 was observed. These results demonstrate the utility of DNA shuffling as an attractive tool to create tetravalent chimeric dengue DNA vaccine constructs, as well as a need to find ways to improve the immune responses elicited by DNA vaccines in general.