Intended for healthcare professionals

Rapid response to:


GMC guidance on end of life care

BMJ 2010; 340 doi: (Published 22 June 2010) Cite this as: BMJ 2010;340:c3231

Rapid Response:

A care bundle to improve end of life care in hospitals

Bell[1] helpfully reviews the new GMC guidance[2] “Treatment and care
towards the end of life”, which raises expectations of clinical practice
around identification of patients approaching the end of life as well as
provision of information, escalation decisions, determination of
preferences, clear team communication and documentation. While welcomed,
this poses a challenge for those working in acute hospitals, particularly
in services with large numbers of end of life care patients such as acute
medicine, oncology and critical care. It requires a systematic approach to
effective assessment of end of life care needs, communication with members
of the multi-disciplinary team and development of a plan shared with the
patient and carer.

We have found in our hospital that clinical decision making around
end of life care is performed inconsistently for patients whose recovery
is uncertain and key planning meetings involving the patient and their
carers may be omitted. Our baseline indicated that only one in 10 patients
received three key elements of best practice care.

At the Modernisation Initiative End of Life Care Programme[3], we
have addressed this problem by developing the AMBER care bundle with the
aim of providing high quality, systematic, auditable care to those at risk
of dying in the next few months. This incorporates four points which can
be answered yes or no easily and rapidly: Medical plan documented?
Escalation decision documented? Nursing staff understand and agree with
medical plan? Patient/carer discussion/meeting held and clearly

Following initial implementation, the bundle is reviewed daily to
pick up on and respond to changes as they occur and maintain effective
communication with patients and carers. This reduces a complex and
challenging assessment to a series of simple points and, most importantly,
drives teamwork and communication.

We have implemented the care bundle so far in forty patients with
improvement in both the quality of team communication and the
effectiveness of communication with patients and carers, with 86 per cent
of patients who died achieving their preferred place of care

Use of a care bundle in an area of clinical complexity such as end of
life care in a general ward is an extended use of a care bundle which more
typically quality controls specific treatment pathways[4]. However, we
have found that the simplification, clarity of focus and the requirement
to improve the quality of team communication is a very effective way of
implementing and sustaining change. The AMBER care bundle is shortly to be
piloted in a number of sites nationally.


[1] Bell, D. (2010) BMJ 2010;340:c3231

[2] General Medical Council (2010) Treatment and care towards the end
of life: good practice in decision making. Guidance for doctors. www.gmc-

[3] The Modernisation Initiative End of Life Care Programme is funded
by the Guy’s and St Thomas’ Charity with support from the King’s College
Hospital Charity and South London and Maudsley Charitable Funds.

[4] NHS Modernisation Agency (2007) 10 High Impact Changes for
Service Improvement and Delivery: High Impact Change Six: Increase the
reliability of performing therapeutic interventions through a Care Bundle
approach. NHS Institute for Innovation and Improvement.

Competing interests:
None declared

Competing interests: No competing interests

06 July 2010
Dr Irene Carey
Consultant in Palliative Medicine
Dr Adrian Hopper, and Michelle Morris.
Guy's and St Thomas' Foundation Trust SE1 7EH