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
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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
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(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 facility
providing palliative and end of life care, alongside
respite support for patients at an earlier stage of
illness.
Integrated Palliative Care Team work very closely
with SGWH
• refer patients
• Specialist MDT
GP
Complementar
y therapies
Hospital
teams
OT/Physioth
erapist
Consultants
Diversional beds
Lymphodema
Integrated specialist
team
Information
Hospice
CAB
Community
nursing
teams
Bereavement
services
LTC CNS
Day hospice
CNS
Hospital/Co
mmunity
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
Thank you for listening
Any questions?