1. Facilitator: Step 3 1

2. Review / Recap Step 2 workshop review Review of ‘To Do’ List Reflection discussions 2

3. 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 3

4. Step 3 Co-ordination of care “Once a care/support plan has been agreed, it is important that all services are effectively co- ordinated, 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 4

5. Communication systems Multi-disciplinary teams Referral systems 24/7 cover Methods of communication 2 way communication 5

6. Good communication Benefits of effective communication in end of life care V Risk of ineffective communication in end of life care Discussion point 6

7. 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) 7

8. The role of the Key Work er Review of needs Communication link Support Advocate 8

9. Anticipatory needs Being ready to meet the individual’s needs without delay:  Individual, changed or increased needs  Medications  Equipment provision 9

10. 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-ordinatio n 10

11. Hospital admissions Group activity: Hospital admission case study: Did the person die in the appropriate setting? Was the setting of their choice? 11

12. 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 12

13. Onwards... ‘To Do’ List Reflective practice Evaluation of session Next session: Step 4: Delivery of high quality care in domiciliary care 13