Transcript Network End of Life Care Home Link Nurse

STEP 3 - CO-ORDINATION OF CARE
Step 3 - Co-ordination of Care
Objectives:
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Anticipating care
Sharing information - the wider MDT
Anticipatory medication
Out of Hours
The Key Worker
Portfolios, Step 3 To Do List
End of Life Care Policy
Evaluations
DNAR in advance care planning
Co-Ordination of Care
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Anticipation - key to effective service provision
Effective communication
Information gathering
Information sharing
Ownership, responsibility
Clear plans - shared
Remember •
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Consent
Documentation
Sharing the plan of care, information
Reviewing the plan of care, updating, sharing
Co-ordination of Care
“If a patient is likely to live for a matter of
weeks, days matter, if the prognosis is
likely to be days, hours matter.”
End of Life Care Strategy, DH 2008
Co-ordination of Care
• Co-ordination - may require multiple agencies at
different times, e.g. home, hospital, care home,
hospice
• Need to be aware of available services
• Co-ordination is a major activity
• Whose responsibility? - Can take away from direct
delivery of care
• Lack of co-ordination = Increased chance of dying in
place not of choice
Co-ordination of Care
Need to consider at different levels:
• Within an individual team
• Between teams
• Across organisational boundaries
Out of Hours Care
Why is it important?
In a seven day week, 75% of the time falls OOH
‘From my own palliative care patients I would
hope that I would have them well enough
organised in hours that they wouldn’t need to
call out of hours.’
Problems perceived by OOH’s
Lack of information
Problems perceived by OOH GPs
• Lack of information on patient OOH
• Workload, time pressures
• Unexpected deterioration
• Lack of skill/knowledge?
“Even in the best service/team things go wrong and
you can’t always know what’s going to happen.
People deteriorate very suddenly… suddenly they
think they can’t do it and it’s a crisis.”
“The easiest thing to do OOH is to send them in – that
solves the problem. You don’t have to go back, you
know they will be taken care of. I don’t mean to
sound cynical about that. You are moving from one
patient to the next very quickly in a busy night –
these sort of patients need a bit of time.”
‘The main difficulty is… going into a situation
cold and trying to judge everyone’s agenda.’
What is best for patients?
Effective anticipatory care to
reduce the need for OOH calls
Out-of-hours (OOH) issues
– ideally anticipatory prescribing already in place
– need to be aware of issues when not in place or
unexpected deterioration occurs
– OOH can also do anticipatory prescribing – may
reduce further visits
– good communication needed OOH, especially with
family and district nurse team
Two roads to death
Managing end of life care (how to
avoid the difficult road)
– anticipation
– co-ordination
– explanation
– comfort
– support
Anticipating symptoms
How common are symptoms in
terminal phase?
Common symptoms in Terminal
Phase
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noisy breathing (secretions) : 56%
pain
: 51%
agitation/restlessness
: 42%
urinary incontinence
: 32%
breathlessness
: 22%
urinary retention
: 21%
nausea and vomiting
: 14%
jerking/twitching
: 12%
confusion
: 9%
Macmillan Cancer Support/Medicines
Management Network, 2008
Anticipatory Prescribing
Advantages • Improved symptom control
• Reduces stress/anxiety in carers
• Assists OOH services inexperienced in
palliative care
• Prevents hospital admission
• Cheaper than OOH visit
• Patient centered
Anticipatory prescribing
Disadvantages • GP’s reluctant to prescribe
• Need to broach subject of deterioration/dying
earlier in patient journey
• Inconsistencies in prescribing
Anticipatory medicines
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Morphine Sulphate
Cyclizine
Haloperidol
Metocloprimide
Levomepromazine
Midazolam
Glycopyronium
Medications in dying phase
• Access to pharmacies OOH
• Access to pharmaceutical advice OOH
• Whole team aware of process/resources?
Role of the Key Worker
NICE (2004) defines the Key Worker as:
“a person who, with the patients’ consent and
agreement, takes a key role in co-ordinating
the patients care and promoting continuity,
ensuring the patient knows who to access for
information and advice’.
Key Worker
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Regular review of residents needs
Link between services for a designated resident
Lead in the co-ordination of assessment of needs
Lead in the co-ordination of care
Communicating with resident, relatives, health and
social care professionals
• Ensuring communication within own team of
individual resident
End of Life Care Checklist
Summary
Co-ordination of care
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Anticipating Care
Sharing information, referral systems
Out of Hours
Key Worker
Anticipatory medication
Portfolios, Step 3 To Do List
End of Life Care Policy
DNAR in advance care planning
Evaluations