Presentation on theme: "Community Palliative Care Team What do we do?"— Presentation transcript:
1 Community Palliative Care Team What do we do? Dr Faith CranfieldMedical Lead, Community Palliative Care Team,St Francis Hospice
2 BackgroundHome care service established by daughters of charity in – in a portacabin in Capuchin Friary in Raheny1995 – Inpatient unit (19 beds) opened SFH RahenyTwo community teams – East and West2011 – West team moved to new SFH Blanchardstown
4 Who do we see?Cancer patients. All have incurable, progressive disease. Some continue palliative chemotherapy.Patients with MNDPatients 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 decision- making.Children with life-limiting illnesses
5 Location of care Home Nursing homes Homeless hostels Long term psychiatric hospitalsSheltered accommodation
6 Team membersNurses 14 WTE CNS, including 1 WTE Management (0.5 East CNM, 0.5 West CNM)Medical director ¾ WTE2 Registrars2 Full-time Chaplains2 WTE Social workers
7 Activity 2012 New referrals: 974. New patients taken on: 702. Referral source: GP-204Beaumont-261Mater-228James Connolly-39Other 260Nursing visits 8557, Medical visits 693Deaths 701.Home-323,St Francis Hospice -626,other -390
8 What The CPC Team Can Offer Specialist palliative care to patientsSpecialist palliative advice on patient management to professionals (GPs, nursing home staff)Support for patient’s family and professional carers24 hour availability of telephone advice
9 Working hoursMon- Fri normal working hours – regular phone calls and visits4:30-9pm Single nurse on call for North Dublin, can do home visit if necessary9pm til 8:30 am Telephone advice via night nurses in Inpatient Unit in Raheny
10 Accessing the service Referral received Next working day: urgency for visit categorised based on need – diagnosis and disease extent, prognosis, functional status, palliative care needsWaiting 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.
11 Where do we fit in? GP remains primary carer Hospital care continues as appropriateOngoing 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
12 Input by CPC TeamVisits by CNS– frequency will depend on needs, patient preference, patients hospital appointments etc. Often weekly.Social work assessments/supportAt home/at hospice/Family meetingsChaplaincy visits at homeReferral to Day care or Inpatient care as appropriateVolunteer Service
13 Introduction of Hospice Often emotional – for patient and familyBreaking bad newsDyingAnxiety re: changing care/healthSense of abandonmentGetting to know new team of health care professionals
14 Challenges Establishing a good rapport – trust Dealing with collusion Balancing patient and family needsNot meeting expectations e.g. hands on careEnsuring consistency amongst healthcare professionals information
15 Assessment Symptom assessment – physical. Clarifying medication. Addressing emotional / psychological / spiritual concernsAddress family concernsOffer counselling / supportOffer volunteersDaycareIn-patient CareLiaise with other health care professionals
17 Psychological Issues Loss of role Worry about family Loss of dignity / privacyFear of dying in painFinancial difficultiesThe meaning of lifeLoss of futureHelplessness / being a burdenAnxietyDepressionFear of deathLoss of control
18 Psychological Issues for Family Grief and distressExhaustion – emotional and physicalCoping with competing demandsTheir loved ones distressedUnfamilarity with death and dyingFear of what is to comeFear of being incompententFear of doing harmDisagreement/discord within family
19 Spiritual distressTrying to make sense of things –the Why? Of what is happening.Trying to find meaningConcerns about afterlifePrayer for support
20 Decision making at home -in the event of physical change What do we think is the cause?InformationAccess to tests. Mostly clinical assessment, +/- CITIs 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?
21 Medication Huge source of distress Poor swallow Weakness Drowsiness Under dosageOver dosage
22 Nutrition Food important part of life - Shows love and concern - Sharing / nurturingFood becomes a burdenIssue of starvationNatural processBurden and benefit
23 Physical Environment House Stairs Downstairs Toilet Unsuitable accomodationLack of equipmentLack of carers
24 Example –JD, 48JD, 48 y/o lady with metastatic non-small cell cancer. On chemotherapy. Separated working mother, self- employed. 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.
25 Develops vomiting. Due to see solicitor at home that evening re: will etc SC infusion antiemetic. GP review. Bloods by CIT – hypercalcaemia and uraemiaGlad of admission via day ward for fluids and bisphosphonateD/C home on SC infusion. Stopped after a few days.
26 Develops back pain – known bony vertebral disease 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.
27 Back pain escalates over a week –medications titrated with GP 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.
28 Difficulties For CPC Team Working In Other Institutions Nursing home staff fill dual role – professional carer / locum family memberHomecare assumptions re: nurse/carer familiarity with palliative drugsDifficulty meeting family members – unlike homeChanges in medication often slower to achieve than in the home
29 Liaising and communicating With whom?The patientThe familyThe GPThe PHNIrish Cancer Society Night nursing serviceCITThe Hospital teamA and E
31 Misconceptions We visit at anytime We stay all the time We come when someone diesWe come in an emergencyWe replace all other community services – we come in and take overWe have immediate access to bedsWe arrange everythingWe insist people know we are from the hospice
32 Why do it? Achievement – Enabling family to cope Enabling patient to die at homeImproving someone’s subjective quality of life –when time is short, the quality of each day can become very importantChallengingPrivilege