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Option 5 – Nurse led Palliative Care Assessment & Rehabilitation
1. Option description
1.1.
Nurse led Palliative Care Assessment & Rehabilitation
1.2. Description of change
Designation of six palliative care beds (incorporating the two existing end of life
care beds) within the Newton Wing of the Town & County Hospital in Wick for
the delivery of holistic multi disciplinary assessment to patients requiring
palliative care. The staff will have the skills to talk to individuals and their
families about dying; time to listen to the concerns of those individuals and
families; time to support individuals and families to plan effectively for future
care needs; and additional skills in symptom control management. They will
also have close links with the multi disciplinary and palliative care teams to
ensure the right level of care in all settings as per individual wishes. This will be
done through regular multidisciplinary meetings and individual case
conferences.
Situation
“Patients with the most complex needs are usually in hospital. One quarter of
all admissions to an acute hospital have some palliative care needs and one
third of all hospital beds are occupied by patients in their last year of life.” (1)
Patients are currently assessed, by the primary and secondary care teams
within the Caithness hospitals and their home. However there are no
designated palliative care assessment beds in Caithness General Hospital
meaning that people are having their acute care needs assessed but their wider
palliative care needs for support, reablement and daily living aids may not be a
priority in this setting.
End of life care is well supported in Caithness, with patient preference being
met as far as possible within the range of settings. In addition to care being
delivered in the patients’ home, in care homes and in Caithness General
Hospital there are two designated end of life care beds in Town & County
Hospital in Wick and one designated end of life care bed at the Dunbar Hospital
in Thurso.
“In 2007, ~50% of palliative care deaths in Caithness occurred in a hospital
setting, ~28% occurred in the individual’s own home, ~19% in a nursing home
and ~3% a residential home” (2).
Background
The redesign of adult services in Caithness was established in the December of
2012. In March of 2013 the Redesign Reference Group agreed to establish six
task/finish groups one of which is the Palliative Care Group. That group met
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initially in the summer of 2013 and carried out a SWOT Analysis of services in
Caithness. A sub-group was then established to look in more detail at two of
the issues identified by that group, namely the need for a Palliative Assessment
and Rehabilitation Unit and to quantify the unmet need for people and their
families during the Out of Hours period.
The group identified six options:
Option 1: Status Quo.
Option 2 Retain existing end of life beds and create enhanced community
provision without additional inpatient assessment.
Option 3: Palliative Assessment & Rehabilitation Unit in CGH with enhanced
community provision.
Option 4: Palliative Assessment & Rehabilitation Unit in Town & County
Hospital with enhanced community provision. The end of life care beds in both
the Dunbar and the Town & County Hospitals would remain.
Option 5: Palliative Assessment & Rehabilitation Unit in the Dunbar Hospital
with enhanced community provision. The end of life care beds in both the
Dunbar and the Town & County Hospitals would remain.
Option 6: Palliative Assessment and Rehabilitation Units in the Town & County
and Dunbar Hospitals with enhanced community provision. The end of life care
beds in both the Dunbar and the Town & County Hospitals would remain.
Assessment
The Sub Group identified the pros and cons of each option. (See appendix 1).
Group members then submitted individually their favoured options.
Recommendations
The sub group recommends the following option be taken forward.
Palliative Assessment and Rehabilitation Unit in Town & County Hospital with
enhanced community provision
- Re-designation of beds at Newton Wing, Town & County Hospital to include
four palliative care assessment beds.
- Retain two end of life care beds in Wick (at T&C)
- Retain end of life care bed in the Dunbar, Thurso
- Staff with additional time to provide palliative care support for patients and
staff in all care settings
- Enhanced support for patients and carers
1.3. Reasons for change
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To provide an environment for in-patient holistic palliative care
assessment within Caithness, ensuring that the individual’s potential is
maximised and appropriate care packages are arranged prior to
discharge.
To offer individuals and families the opportunity to work out what is
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important for them by providing the physical and emotional space for
talking, listening and comfort which is difficult in a busy acute ward.
To support individuals in self-management, by developing pathways which
allow patients to access existing services and resources.
To act as a model of best practice and a hub for maintaining competencies
To be a hub for a multi-disciplinary palliative care team.
To act as a hub for Transforming Care After Treatment (TCAT), which
aims to support and enable cancer survivors to live as healthy a life as
possible for as long as possible.
It would also provide additional support to carers and family members.
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2.
Evidence
The Scottish Government (2007) gave a commitment to the delivery of high
quality palliative care to everyone in Scotland who needs it, advocating that
timely, holistic and effective care planning should be available for those with
palliative and end of life care needs,… person centred and responsive to the
needs and diversity of the population (3).
The Scottish Government (2008) recognised the importance of high quality coordinated care that supports patients and carers with palliative and end of life
care needs (4). There are no designated palliative care assessment beds in
Caithness. Patients are currently assessed, by the primary and secondary
care teams within the Caithness hospitals and their homes.
There are two designated end of life care beds in Town & County Hospital in
Wick and one designated end of life care bed at the Dunbar Hospital in
Thurso. End of life care is also delivered in Caithness General Hospital
(CGH) and in the community; there are no other designated end of life care
beds in Caithness.
“There . . . considerable advantages in hospitals designating particular wards
or areas for palliative and end of life care” (5).
As previously stated “In 2007, ~50% of palliative care deaths in Caithness
occurred in a hospital setting, ~28% occurred in the individual’s own home,
~19% in a nursing home and ~3% a residential home” (6).
2.1. Access
Town & County Hospital in Wick has following transport links:
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Stagecoach bus service to within 400 yards of the hospital
400 yards off the A99
Within walking distance to train station
Caithness rural transport (Dial-A-Ride) available
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The building itself has:
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Wheelchair access
Car park and ambulance turning point.
A leaflet is available detailing further access information
2.2. Equity
The level of care and/or support will ensure that people are treated with fairness
and transparency, promoting people’s rights and supporting choice.
Assessment by skilled professionals working with the person and their family will
fully identify the services within the county required to enable this group to
achieve their preferred place of care.
2.3. Improved outcomes
This proposal would utilise the existing expertise and facilities at the Newton
Wing of Town & County.
There would continue to be “end of life care beds” in both Wick and Thurso for
those who chose this as their preferred place of death. These beds would also
be available for symptom management.
The four additional assessment and rehabilitation beds would be for people with
palliative care needs, including those with long term conditions, judged to be in
their last year of life. These will provide high quality care, focusing on the
treatment of pain and other distressing symptoms as well as addressing social,
spiritual, psychological and family needs. The beds would also act as a
resource to reduce admissions to acute beds (at CGH) and act as “step down”
beds for those people diagnosed in acute care settings as palliative and who
require a level of rehabilitation and the arrangement of a suitable care package
prior to their discharge from hospital. Health Care Assistants (HCAs) would
undergo additional training to support the physiotherapy and occupational
therapy needs of those admitted to the beds in order to help them maximise
their potential.
2.4. Effective practice
There will be continuity of care and/or treatment and/or support, designed to match
the needs of the individuals and their carers i.e. right service, at the right time, in
the right place, by the right provider. Care and support will be delivered to the
highest possible standards of quality, safety and evidence, with the person being at
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the centre of all decisions. Risks will be assessed and managed.
The unit would increase educational opportunities for acute hospital staff, many of
whom have no formal training in palliative care, by allowing rotation of staff from
other wards.
2.5. Sustainable
The proposals will allow us to enhance the skills of the staff in terms of the
assessment of patients and also their skills in end of life care.
Working and engaging with the wider team we will make services more
sustainable. Strengthening the assessment process will help us work with
individuals to anticipate care requirements and allow people to maximise
independence throughout their palliative journey.
Care plans will be flexible enough to adapt to changing circumstances for the
individual.
2.6. Culture and values
For those using the assessment and rehabilitation beds there will be a full
assessment of needs by the multi-disciplinary team, whose underlying ethos is
to maximise potential.
It will provide the support to arrange packages of care, if required, for those
going home.
Principally it will provide the individual and family with choice. The environment
will provide the physical and emotional space for those individuals and families
to identify what is important to them.
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4.
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Risks
Inability to engage community and staff in the change process.
Funding of project.
Other competing demands for the Town and county unit.
Staffing; ability to recruit and retain
Implications for others
Potential to reduce inappropriate admission to Caithness General Hospital.
Potential to facilitate earlier discharge from hospital thereby reducing length
of stay.
Further development of the multi disciplinary team; maximising people’s
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5.
potential for independence.
Potential to provide care to people in their locality, reducing travel time and
cost for both them and their family.
Potential implication to consultant job plan
Potential to roll out to other areas following completion of evaluation
Consultation
The proposal was drafted by a sub group of the Palliative Care Task/Finish
Group, itself a sub group of the Redesign of Adult Services in Caithness. The
proposals, along with the alternative proposals have been discussed by the
group. Members of the group individually signalled their preferred option.
During the development of this proposal there have been at least two meetings
of the Reference Group. The Palliative Task Group has presented its plans in
outline at these meetings and sought approval to continue to develop its plans
further.
6.
References
Appendix 1
(1) Review of palliative care services in Scotland. Audit Scotland 2008
(2) “Epidemiology and Palliative Care”. S Vaughan (NHS Highland) 2008
(3) Better Health Better Care. Scottish Government (2007)
(4) Living and Dying Well. Scottish Government (2008)
(5) “More Care; Less Pathway”. Neuberger (2013)
(6) “Epidemiology and Palliative Care”. S Vaughan (NHS Highland) 2008
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