Community Palliative Care Team

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Community Palliative Care Team
What do we do?
Dr Faith Cranfield
Medical Lead, Community Palliative Care Team,
St Francis Hospice
Background
 Home care service established by daughters of charity in
1989 – in a portacabin in Capuchin Friary in Raheny
 1995 – Inpatient unit (19 beds) opened SFH Raheny
 Two community teams – East and West
 2011 – West team moved to new SFH Blanchardstown
Catchment Area
Who do we see?
 Cancer patients. All have incurable, progressive disease. Some
continue palliative chemotherapy.
 Patients with MND
 Patients with other progressive fatal diseases –terminal care
patients receive full service. Others receive Palliative Medicine
review to advise GP on symptom management, end of life decisionmaking.
 Children with life-limiting illnesses
Location of care
 Home
 Nursing homes
 Homeless hostels
 Long term psychiatric hospitals
 Sheltered accommodation
Team members
 Nurses 14 WTE CNS, including 1 WTE Management (0.5 East
CNM, 0.5 West CNM)
 Medical director ¾ WTE
 2 Registrars
 2 Full-time Chaplains
 2 WTE Social workers
Activity 2012
New referrals: 974. New patients taken on: 702.
 Referral source: GP-204




Beaumont-261
Mater-228
James Connolly-39
Other 260
 Nursing visits 8557, Medical visits 693
 Deaths 701.
 Home-323,
 St Francis Hospice -626,
 other -390
What The CPC Team Can
Offer
 Specialist palliative care to patients
 Specialist palliative advice on patient management to
professionals (GPs, nursing home staff)
 Support for patient’s family and professional carers
 24 hour availability of telephone advice
Working hours
 Mon- Fri normal working hours – regular phone calls
and visits
 4:30-9pm Single nurse on call for North Dublin, can do
home visit if necessary
 9pm til 8:30 am Telephone advice via night nurses in
Inpatient Unit in Raheny
Accessing the service
 Referral received
 Next working day: urgency for visit categorised based on need –
diagnosis and disease extent, prognosis, functional status, palliative
care needs
 Waiting time: variable –urgent referrals warrant telephone contact
to explain what the need is, identify if a visit is possible.
 First visit. Once seen, patients given contact details and can access
24 hour advice.
Where do we fit in?
 GP remains primary carer
 Hospital care continues as appropriate
 Ongoing nursing telephone support and visits (NB all changes
warrant review of effectiveness)
 PHN continues to review for pressure care needs, dressing
needs, assessment and access to community
physiotherapy/OT and to home carer support
Input by CPC Team
 Visits by CNS– frequency will depend on needs, patient
preference, patients hospital appointments etc. Often weekly.
 Social work assessments/support
 At home/at hospice/Family meetings
 Chaplaincy visits at home
 Referral to Day care or Inpatient care as appropriate
 Volunteer Service
Introduction of Hospice
Often emotional – for patient and family
Breaking bad news
Dying
Anxiety re: changing care/health
Sense of abandonment
Getting to know new team of health care professionals
Challenges
 Establishing a good rapport – trust
 Dealing with collusion
 Balancing patient and family needs
 Not meeting expectations e.g. hands on care
 Ensuring consistency amongst healthcare professionals
information
Assessment
 Symptom assessment – physical. Clarifying
medication.
 Addressing emotional / psychological / spiritual
concerns
 Address family concerns
 Offer counselling / support
 Offer volunteers
 Daycare
 In-patient Care
 Liaise with other health care professionals
Physical Symptoms
 Fatigue/Lack of
energy/Weakness
 Anorexia
 Pain
 Dry mouth/sore mouth
 Nausea
 Early satiety
 Vomiting
 Constipation
 Diarrhoea
 Dyspnoea
 Cough
 Delirium
 Poor sleep
 Restlessness
 Falls
Psychological Issues
 Loss of role
 Worry about family
 Loss of dignity / privacy
 Fear of dying in pain
 Financial difficulties
 The meaning of life
 Loss of future
 Helplessness / being a
 Anxiety
burden
 Fear of death
 Loss of control
 Depression
Psychological Issues for
Family
 Grief and distress
 Exhaustion – emotional and physical
 Coping with competing demands
 Their loved ones distressed
 Unfamilarity with death and dying
 Fear of what is to come
 Fear of being incompentent
 Fear of doing harm
 Disagreement/discord within family
Spiritual distress
 Trying to make sense of things –the Why? Of what is
happening.
 Trying to find meaning
 Concerns about afterlife
 Prayer for support
Decision making at home -in the
event of physical change
 What do we think is the cause?
 Information
 Access to tests. Mostly clinical assessment, +/- CIT
 Is it reversible? Will treating the cause change the
outcome? Does this warrant admission?
 What are the symptoms and how can we alleviate them?
 What does the patient want?
 In light of the change, is the situation sustainable?
Medication
 Huge source of distress
 Poor swallow
 Weakness
 Drowsiness
 Under dosage
 Over dosage
Nutrition
 Food important part of life

- Shows love and concern

- Sharing / nurturing
 Food becomes a burden
 Issue of starvation
 Natural process
 Burden and benefit
Physical Environment
 House
 Stairs
 Downstairs Toilet
 Unsuitable accomodation
 Lack of equipment
 Lack of carers
Example –JD, 48
 JD, 48 y/o lady with metastatic non-small cell cancer. On
chemotherapy. Separated working mother, selfemployed. Two children.
 Seen at home. Angry, wary. Concerns raised re: teenage
daughter – acting up, not aware of extent of disease.
Planning for future care of daughters.
 Chemotherapy poorly tolerated –vomiting, sepsis.
Stopped.
 Recovers partially. Family meeting re: illness.
 Develops vomiting. Due to see solicitor at home that
evening re: will etc
 SC infusion antiemetic. GP review. Bloods by CIT –
hypercalcaemia and uraemia
 Glad of admission via day ward for fluids and
bisphosphonate
 D/C home on SC infusion. Stopped after a few days.
 Develops back pain – known bony vertebral disease.
Settles with opioids –problematic constipation. Referred
to radiation oncology. Receives thoracic XRT.
 Progressive weakens over weeks. Spending much of the
day in bed. Worried re: children. Expressing wish to die
in hospice, but stay at home as long as manageable.
 Back pain escalates over a week –medications titrated
with GP. Falls secondary to leg weakness and difficulty
passing urine.
 Catheterised. Listed for admission to St Francis. No bed.
Night-nurse organised.
 Bed becomes available. JD admitted to St Francis for
terminal care. Dies after a two week admission.
Difficulties For CPC Team
Working In Other Institutions
 Nursing home staff fill dual role – professional carer / locum family
member
 Homecare assumptions re: nurse/carer familiarity with palliative
drugs
 Difficulty meeting family members – unlike home
 Changes in medication often slower to achieve than in the home
Liaising and communicating
With whom?
 The patient
 The family
 The GP
 The PHN
 Irish Cancer Society Night nursing service
 CIT
 The Hospital team
 A and E
Anticipatory planning
Misconceptions
 We visit at anytime
 We stay all the time
 We come when someone dies
 We come in an emergency
 We replace all other community services – we come
in and take over
 We have immediate access to beds
 We arrange everything
 We insist people know we are from the hospice
Why do it?
 Achievement – Enabling family to cope
 Enabling patient to die at home
 Improving someone’s subjective quality of life –when time is short, the
quality of each day can become very important
 Challenging
 Privilege
Thank you for listening
Any questions?
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