Transcript Slide 1

Facilitator:
Step 3
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Review / Recap
• Step 2 workshop review
• Review of ‘To Do’ List
• Reflection discussions
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Objectives
Step 3 objectives:
• Identify the value of good communication systems in end of life care
• Recognise the importance of sharing information with the wider
multi-disciplinary team
• Recognise the key features and values of the role of the key worker
• Be aware of aspects of anticipatory needs at the end of life
• Identify necessary and unnecessary admissions to acute care
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Step 3
Co-ordination of care
“Once a care/support plan has been agreed, it is
important that all services are effectively coordinated, especially across service boundaries,
and good communication systems are in place.”
The Route to Success in End of Life Care – achieving quality in
domiciliary care
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Communication systems
• Multi-disciplinary teams
• Referral systems
• 24/7 cover
• Methods of communication
• 2 way communication
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Good communication
Benefits of effective communication in
end of life care
V
Risk of ineffective communication in
end of life care
Discussion point
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Key Worker
A key worker is defined as:
“A person who, with the patient’s consent and
agreement, takes a key role in coordinating
the individual’s care and promoting continuity,
ensuring the patient knows who to access for
information and advice” (NICE, 2004)
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The role of the Key Worker
• Review of needs
• Communication link
• Support
• Advocate
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Anticipatory needs
• Being ready to meet the individual’s needs
without delay:
Individual, changed or increased needs
Medications
Equipment provision
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Anticipatory needs
• Referral to relevant others
• Specific medications for relief (pain, distress,
breathing difficulties, bowel upset,
nausea/sickness, etc)
• Equipment to improve quality of life and comfort
• Active communication and co-ordination
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Hospital admissions
Group activity:
Hospital admission case study:
• Did the person die in the appropriate setting?
• Was the setting of their choice?
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Objectives
Step 3 objectives:
• Identify the value of good communication systems in end of life care
• Recognise the importance of sharing information with the wider
multi-disciplinary team
• Recognise the key features and values of the role of the key worker
• Be aware of aspects of anticipatory needs at the end of life
• Identify necessary and unnecessary admissions to acute care
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Onwards...
• ‘To Do’ List
• Reflective practice
• Evaluation of session
• Next session: Step 4: Delivery of high
quality care in domiciliary care
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