Clinical outcomes are measurable changes in health, function or quality of life that result from our care. Constant review of our clinical outcomes establishes standards against which to continuously improve all aspects of our practice.
About the Paediatric Palliative Care Service
The Specialist Paediatric Palliative Care (SPPC) service at Great Ormond Street Hospital (GOSH) provides care to children with life-limiting and life-threatening conditions and their families. We are the largest SPPC team in the UK and receive around 200 new referrals every year. Some patients are with our service for a short time, while others receive palliative input for several years.
The service works with other hospital, community and hospice teams to ensure children and families receive coordinated care for their condition. We specialise in managing complex symptoms and helping our patients make difficult decisions regarding care when cure is not possible and living to adulthood is unlikely.
Every child and family is different, and the team provides a variety of types of support depending on a patient’s needs. For those children who reach the end of their life whilst under our care, this includes helping them and their families to be where they want to be when they die. We call this a child and family’s 'preferred place of death'. The clinical outcomes we report below measure this aspect of our service.
Clinical outcome measures
To demonstrate our treatment effectiveness and to inform our commitment to continuous improvement, in September 2013 we began to collect more data about our service. Here, we report data on deaths recorded by the service between April 2014 and March 2018, for which all of these measures are relevant:
1. How many of our patients die at home?
We include this metric because it is a national measure for palliative care. We believe offering choice of place of care at the time of death is essential. Home is often cited as the preferred place of death for children, but there is no strong evidence to support this .
Home should be included as one of these choices, but no family should feel pressurised into caring for their child at home or that they have ‘failed’ if they or their child feel this is not the right place. However, for those who feel that home is the right choice, we need to make sure that we can work with the family and community teams to ensure they have the around-the-clock support they need.
Figure 1.1 Percentage of children who died at home, 2014-15 to 2017-18
 Bluebond-Langner M, Beecham E, Candy B, Langner R, Jones L (2013) Preferred place of death for children and young people with life-limiting and life-threatening conditions: a systematic review of the literature and recommendations for future inquiry and policy. Palliat Med 27(8): 705-13.
2. How many patients/families were offered a discussion on their preferred place of death?
It is important that children and families are part of decisions relating to their end-of-life care and that their preferences are taken into account by the healthcare professionals involved. This includes being able to discuss where they want to be at death, and this is something the SPPC team can help with.
Sometimes it is not possible to have these conversations. For example, a child or family may not feel able to consider death as a possible outcome, so are not able to engage in considering a preferred place. There can also be occasions when a child cannot be moved without causing immediate injury or death. However, in cases where it is appropriate to have this conversation, we aim to ensure that the child and family’s voices are heard, and we collect this data as a measure of the effectiveness of our care.
Figure 2.1 Percentage of children / families offered a discussion about preferred place of death, 2014-15 to 2017-18
Of those patients who died whilst under our care and for whom a discussion of preferred place of death was appropriate, almost all (99.7%, n=316) were offered a discussion.
3. How many patients/families achieved their preferred place of death?
Discussing preferred place of death with a child and their family is one important step, but we must then endeavour to achieve those preferences. This can involve coordinating services inside and outside hospital and providing specialist symptom management support so that high-quality care can be provided at the end of life in the chosen setting. This also involves supporting the child and their family if their preference changes.
Figure 3.1 Percentage of children / families who achieved their preferred place of death, 2014-15 to 2017-18
Of those patients who died whilst under our care and who discussed their preferred place of death with us, 94 per cent (n=262) achieved their preference. Three per cent were undecided or a consensus between family members had not been agreed. Four per cent of children and families did not achieve their preferred place of death. (Figures add to over 100 per cent due to rounding.)
We will continue to collect and review the data about the services we provide, and to seek to add more measures that tell us about our effectiveness.
This information was published in November 2018 and will be updated in November 2019.