Download 6 Steps to success in end of life care

Step 3 workshop
Step 3 workshop
Co-ordination of care
Communications:
• Communicating with others/accessing
information
• Co-ordination of Care (including the role of the
Key Worker)
• Communication in practice including the use of
‘PREPARED’ and an interactive demonstration
Co-ordination within the
organisation
Why is good communication important to good
end of life care?
Co-ordination of Care
•
•
•
•
Co-ordination – who is involved???
Need to be aware of available services
Co-ordination is a major activity
Whose responsibility? - Can take away from direct
delivery of care
• Lack of co-ordination = Increased chance of dying in
a place not of individual’s choice
Review Sheet
Advancing disease
1
Years to live
Holistic Assessment
Name:_________________________
□
Holistic Assessment
□
Increasing decline
2
Last Days of Life
3
First Days after Death
4
recorded
□
Key/Lead worker nominated
□
DNACPR in place
□
Verification of death
□
Follow-up bereavement
contact
Advance Care Plan review
□
Certification of death
□
In place
□
□
Signpost to bereavement
counselling services if required
Family discussion
□
□
Bereavement leaflet
□
Offered
Advance Care Plan:
Offered
In place
□
□
Assessment carried out by:
Family discussion
□
District Nurse
Assess equipment needs
GP
DN
Continuing health care
Assessment carried out by
□
□
□
□
Holistic Assessment
Advance Care Plan:
Advance Care Plan wishes
Bereavement
5
funding review
Assess equipment needs
□
□
□
□
Anticipatory drugs
prescribed and available
Is there an End of Life Care Plan
What to do ‘After a Death’
for the Dying Patient in place (or
Booklet
equivalent)
□
Out of Hours handover form
completed:
OOH GP
OOH DN
Is it known if Out of Hours
handover form has been
completed:
OOH GP
OOH DN
Anticipatory drugs available
□
□
□
□
Ambulance service updated □
Syringe driver available
GP Assessment
□
□
□
□
Complete Post Death
□
Information Audit Form
Inform all relevant health
and social care professionals
□
Is ambulance service updated
□
Significant Event Analysis
Support for staff
□
□
□
Communication in the
organisation
• What communication systems do you have
within your organisation?
The Key Worker
• Does the individual have a key worker external
to your organisation?
– Who?
– How do you know/record that information?
– How or why would you need to contact them?
• Does your organisation have a key worker
role?
The role of the key worker
• A person who with the patients consent and
agreement takes a key role in co-ordinating the
patient’s care and promoting continuity, ensuring the
patient knows who to access for information and
advice
Nice Improving Supportive & Palliative Care for Adults with Cancer (2004)
Do you have a ‘key worker’
type role?
Roles & responsibilities
• Assessment and eliciting needs
• Agreeing care plans
• Communicating between others involved in
individuals care
• Support and advice
• Managing transitions of care
• Managing change of key worker
Sharing Information
• Changes in condition:
•
•
•
•
•
•
•
Staff
Family members
GP
District nurses
Other health professionals
Single Point of Access/OOH
Continuing healthcare (funding)
Do you have a ‘key contacts’ list (office/staff)?
Communication Exercise