Role of the Integrated Specialist Palliative Care Team

Juliet Cross – Palliative Care CNS (community)Sara Smith – Nurse Practitioner- End of Life Care

Definition“An approach that improves the quality of life of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by a means of early identification and impeccable assessment and treatment of pain and other problems physical, psychosocial and spiritual”

World Health Organisation (2006)

Role of the Specialist Palliative Care Nurse

• Improving the quality of life of patients and their families• Identify needs, priorities and preferences• Providing co-ordinated seamless services• Ensuring appropriate support for carers (Day Hospice)• Support integrated care pathways found to improve care and dignity at the end of life• Supporting professionals involved in their care• Providing a high quality service in the last days of life and after death• To ascertain and respond to the educational needs of healthcare professionals• To promote and develop audit and research in areas relating to palliative care

Charlton (2002)

Nurse Practitioner – End of Life Care• Work within the integrated palliative care team• Care for patients in the last days of life• Support family • Support ward staff with symptom control • Refer to Specialist nurse for complex needs• Education• Audit and monitor end of life care in the hospital• Refer patients/families for bereavement/pre bereavement

support• Identify and support preferred place of care at end of life • (St Giles/Nursing homes/own home/Hospital)• Liaise with community teams to ensure smooth transition of

care

Palliative Care Services

• Integrated Palliative Care Team – community/hospital inc. consultants, CNS’ & OT

• Palliative Therapies

• Complementary Therapies

• Volunteers

• Specialist Lymphoedema

• Fair Oaks Day Hospice

• Bereavement Service

• Chaplain Service

• Clinical Psychology

St. Giles Walsall Hospice (SGWH)

St Giles Walsall Hospice is a 12 bed facilityproviding palliative and end of life care, alongsiderespite support for patients at an earlier stage of illness.

Integrated Palliative Care Team work very closely with SGWH • refer patients• Specialist MDT

Integrated specialist team

Palliative care/ EOL Initiatives

Transform: Transforming end of life care in hospital• AMBER care bundle• Advance care planning• EOL care plan• Electronic patient register (EPaCCs/GSF)• Rapid discharge home to die

DNAR: Development of a cross services policy

Diversionary pathway : Access to St Giles hospice Walsall for treatment (2-3 days)

Arboretum Nursing Home- diversionary beds

Any questions?

Thank you for listening