What makes for a 'Top Doc'? An analysis of UK press portrayals of so-called top doctors.

OBJECTIVE: To determine the characteristics of medical practitioners designated 'top doctor' or 'Top Doc' in the UK press. DESIGN: Observational study of news stories related to the term top doctor (or Top Doc) with analysis using data from publicly available databases. SETTING: News reports in the UK press accessed via a database from national newspapers from 1 January 2019 to 31 December 2019, prior to the COVID-19 pandemic. Stories relating to disciplinary/criminal matters were analysed separately. MAIN OUTCOME MEASURES: Results were cross-referenced with the General Medical Council register of medical practitioners for gender, year of qualification, whether on the general practitioner (GP) or the specialist register, and if on the specialist register, which specialty. RESULTS: There was a gender divide, with 80% of so-called top doctors being male. National top doctors had been qualified for a median time of 31 years. Top doctors are widely spread among specialties; 21% of top doctors were on the GP register. Officers of the British Medical Association and the various Royal Colleges are also well represented. 'Top doctors' facing disciplinary proceedings are more overwhelmingly male, working in hospital specialties and less obviously eminent in their field. CONCLUSION: There is no clear definition of a 'top doctor', nor are there objective leadership criteria for journalists to use when applying this label. Establishing a definition of 'top doctor', for instance, via the UK Faculty for Medical Leadership and Management, which offers postnominals and accreditation for high-achieving medical professionals, may reduce subjectivity.

Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation.

OBJECTIVE: To evaluate the care of patients dying in hospital without support from specialists in palliative care (SPC), better understand their needs and factors influencing their care. METHODS: Prospective UK-wide service evaluation including all dying adult inpatients unknown to SPC, excluding those in emergency departments/intensive care units. Holistic needs were assessed through a standardised proforma. RESULTS: 88 hospitals, 284 patients. 93% had unmet holistic needs, including physical symptoms (75%) and psycho-socio-spiritual needs (86%). People were more likely to have unmet needs and require SPC intervention at a district general hospital (DGH) than a teaching hospital/cancer centre (unmet need 98.1% vs 91.2% p0.02; intervention 70.9% vs 50.8% p0.001) and when end-of-life care plans (EOLCP) were not used (unmet need 98.3% vs 90.3% p0.006; intervention 67.2% vs 53.3% p0.02). Multivariable analyses demonstrated the independent influence of teaching/cancer hospitals (adjusted OR (aOR)0.44 CI 0.26 to 0.73) and increased SPC medical staffing (aOR1.69 CI 1.04 to 2.79) on need for intervention, however, integrating the use of EOLCP reduced the impact of SPC medical staffing. CONCLUSION: People dying in hospitals have significant and poorly identified unmet needs. Further evaluation is required to understand the relationships between patient, staff and service factors influencing this. The development, effective implementation and evaluation of structured individualised EOLCP should be a research funding priority.

Cancer centre supportive oncology service: health economic evaluation.

OBJECTIVES: There have been many models of providing oncology and palliative care to hospitals. Many patients will use the hospital non-electively or semielectively, and a large proportion are likely to be in the last years of life. We describe our multidisciplinary service to treatable but not curable cancer patients at University Hospitals Sussex. The team was a mixture of clinical nurse specialists and a clinical fellow supported by dedicated palliative medicine consultant time and oncology expertise. METHODS: We identified patients with cancer who had identifiable supportive care needs and record activity with clinical coding. We used a baseline 2019/2020 dataset of national (secondary uses service) data with discharge code 79 (patients who died during that year) to compare a dataset of patients seen by the service between September 2020 and September 2021 in order to compare outcomes. While this was during COVID-19 this was when the funding was available. RESULTS: We demonstrated a reduction in length of stay by an average of 1.43 days per admission and a reduction of 0.95 episodes of readmission rates. However, the costs of those admissions were found to be marginally higher. Even with the costs of the service, there is a clear return on investment with a benefit cost ratio of 1.4. CONCLUSIONS: A supportive oncology service alongside or allied to acute oncology but in conjunction with palliative care is feasible and cost-effective. This would support investment in such a service and should be nationally commissioned in conjunction with palliative care services seeing all conditions.

How effective is virtual reality technology in palliative care? A systematic review and meta-analysis.

BACKGROUND: The efficacy of virtual reality for people living with a terminal illness is unclear. AIM: To determine the feasibility and effectiveness of virtual reality use within a palliative care setting. DESIGN: Systematic review and meta-analysis. PROSPERO (CRD42021240395). DATA SOURCES: Medline, Embase, AMED, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science were searched from inception to March 2021. Search terms included 'virtual reality' and 'palliative care'. Eligibility: (1) adult (>18 years old) with a terminal illness (2) at least one virtual reality session and (3) feasibility data and/or at least one patient outcome reported. The ROB-2 and ROBINS tools assessed risk of bias. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool assessed the quality of the evidence. Standardised mean differences (Hedges's g) were calculated from the pre- and post-data. A DerSimonian-Laird random effects model meta-analysis was conducted. RESULTS: Eight studies were included, of which five were in the meta-analysis. All studies had at least some concern for risk of bias. Virtual reality statistically significantly improved pain (p = 0.0363), tiredness (p = 0.0030), drowsiness (p = 0.0051), shortness of breath (p = 0.0284), depression (p = 0.0091) and psychological well-being (p = 0.0201). The quality of the evidence was graded as very low due to small sample sizes, non-randomisation methods and a lack of a comparator arm. CONCLUSIONS: Virtual reality in palliative care is feasible and acceptable. However, limited sample sizes and very low-quality studies mean that the efficacy of virtual reality needs further research.

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.

Clinician estimates of prognosis: accuracy and impact-a retrospective inpatient hospice study.

OBJECTIVE: To evaluate the accuracy and impact of clinicians' estimates of prognosis (CEP) in patients referred for hospice inpatient care. METHODS: Retrospective review of 12 months' referrals to a London hospice unit. Data extracted included date of referral, admission and death and CEP. RESULTS: N=383. Mean age 72 years (range 24-101). CEP accuracy: Median survival where CEP was 'days' (n=141) was 7 days (0-164); CEP 'weeks' (n=167) was 14 days (1-538); CEP 'months' (n=75) was 32 days (2-507). Kaplan-Meier survival curves showed significant difference between CEP of 'months' and 'weeks' (p<0.0001); 'months' and 'days' (p<0.0001); but not 'days' and 'weeks' (p=0.1). CEP impact: admission waiting time increased with increasing CEP: CEP 'days' (n=105) median 1 day (0-14); CEP 'weeks' (n=154) median 2 days (0-46); CEP 'months' (n=69) median 3 days (0-46). No significant difference was demonstrated in the number of discharge planning conversations between groups (0.9/patient). CONCLUSIONS: CEP was accurate in over half of the cases but did not adequately discriminate between those with prognoses of days or weeks. CEP may affect the prioritisation given to patients by hospices. Inaccurate CEP on referral forms may influence other aspects of care; however, further research is needed.

Hospital deaths dashboard: care indicators.

OBJECTIVES: We wanted to create a medical/nursing led data collection tool to allow for an ongoing audit of the quality of deaths in a teaching hospital. We wanted to be able to produce a visual summary to monitor our involvement, use of PRN medication, recognition of death, treatment escalation plans and communication aspects. We feel these are good surrogate indicators for quality end-of-life care. METHODS: We designed a purpose built spreadsheet which we have designed as an abbreviated version of the UK national audit tools. We involved a number of our core medical trainees to iterate the data collection so it could be done in a timely manner with a simple training guide. Our collective approach meant we have made this as straightforward as possible to roll out and maintain data collection. RESULTS: We collected 100 cases over a period of 6 months (August 2019 to January 2020). We created a dashboard looking at the core elements of end-of-life care and found bar treatment escalation planning all aspects were completed the majority of the time with near 100% communication to relevant family and friends. CONCLUSIONS: Our sample collection tool provides a useful ongoing indicator for the quality of end-of-life care in the trust and to provide a timely infographic quarterly to feedback to interested members of the trust. We hope to be able to continue over some years to collate themes and trends. We would encourage other hospital teams to adopt our approach.

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.

Symptom burden and clinical profile of COVID-19 deaths: a rapid systematic review and evidence summary.

The spread of pandemic COVID-19 has created unprecedented need for information. The pandemic is the cause of significant mortality and with this the need for rapidly disseminated information for palliative care professionals regarding the prevalence of symptoms, their intensity, their resistance or susceptibility to symptom control and the mode of death for patients. METHODS: We undertook a systematic review of published evidence for symptoms in patients with COVID-19 (with a specific emphasis on symptoms at end of life) and on modes of death. Inclusion: prospective or retrospective studies detailing symptom presence and/or cause or mode of death from COVID-19. RESULTS: 12 papers met the inclusion criteria and gave details of symptom burden: four of these specifically in the dying and two detailed the cause or mode of death. Cough, breathlessness, fatigue and myalgia are significant symptoms in people hospitalised with COVID-19. Dyspnoea is the most significant symptom in the dying. The mode of death was described in two papers and is predominantly through respiratory or heart failure. CONCLUSIONS: There remains a dearth of information regarding symptom burden and mode of death to inform decisions regarding end-of-life care in patients dying with COVID-19. Rapid data gathering on the mode of death and the profile of symptoms in the dying and their prevalence and severity in areas where COVID-19 is prevalent will provide important intelligence for clinicians. This should be done urgently, within ethical norms and the practicalities of a public health, clinical and logistical emergency.