Metro North Health Service District Palliative Care Service Care Pathway

Metro North Health Service District - Redcliffe Palliative Care Service

Care Pathway for Palliative Care

 
Admission to service
Access to palliative care is available to all people based on clinical needs and is independent of diagnosis, age, cultural background or geography.
 
 
REFERRED BY GP.
Referrals
Referrals to the service are accepted from General Practitioners, Domiciliary Nursing Agencies, Specialist referrals regarding inpatients in other wards and other institutions. These referrals are made in person, via fax or a phone call to Palliative Care Director if an admission is requested and to community liaison nursing staff if a clinic appointment needs to be organised or a home visit arranged.
 
REASON FOR REFERRAL
Purpose of referral is to:
  • notify service of potential patient,            
  • organise admission to unit for treatment and/or management
  • arrange an outpatient appointment for clinic review
To facilitate transfer of care the following information/documentation is required:
  • demographics
  • history of disease and staging
  • treatment received
  • current medications
  • symptomology
  • relevant pathology, radiology results
Criteria for admission to the Service/Unit are:-
  • patients to have a cancer diagnosis
  • patients who require Palliative and/or Terminal Care
  • patients who reside within these geographical boundaries
Consultation with Dr’s Bruce Stafford or Boris Chern facilitates direct unit admission. Monday – Friday 0800 – 1600 if bed available. After these hours, patients are admitted via the Emergency Department and transferred to the Unit if a bed is available.
Notify service of potential patient
Patient information and details are kept on file. In the event that the patient may require an admission, telephone support or clinic review- the necessary information/documentation is readily available to assist with patient flow. Potential patients and family are able to visit the unit, meet the staff, are shown the facilities and are provided with a brochure that lists the relevant contact phone numbers of the unit and domiciliary agencies
 
 
PALLIATIVE CARE TEAM
Ongoing and comprehensive assessment and care planning are undertaken to meet the needs and wishes of the patient, their caregivers and family.
Care is coordinated to minimise the burden on patient, their caregivers and family.
The following multidisciplinary team provides a service for patients and families both in the palliative care unit and in the community. This team also provides a consultancy service for patients in other wards throughout the hospital.
  • Director Palliative Care Services             
  • Director Oncology                                 
  • Nursing Unit Manager                                        
  • Specialist Nursing Staff
  • Community Liaison Nurses                    
  • Clinical Psychologist
  • Volunteer Coordinator
  • Volunteers
  • Pastoral Care                           
  • Registrar and Resident  
  • Allied health – access to Allied Health Professionals is provided by Redcliffe
District Hospital and includes:
·         Occupational Therapist
·         Social Worker   
·         Dieticians
·         Speech Pathologists
Additional consultancy services provided upon referral include:
·         Acute pain team
·         Radiation Oncology
 
ADMISSION – management & treatment
  • Director Palliative Care Services
  •  Registrar and Resident             
  • Director Oncology                                 
  • Nursing Unit Manager                                        
  • Specialist Nursing Staff
  • Community Liaison Nurses                    
  • Clinical Psychologist> Emotional support bereavement
  • Volunteers > home respite /massage
  • Social worker > financial advice / Social support
  • Pastoral Care                           
  • Other-   Allied health – access to Allied Health Professionals is provided by Redcliffe – Dietician/ Speech pathologist/ Pain Team
 
CLINICS
Refer to clinics for Assessment / review / arrange admission / chemotherapy / radiotherapy
·         Oncology
·         Palliative Care
·         Psychology
·         Community Liaison Nurse
·         QRI
·         Dietetics
·         Social Work
·         RADIOTHERAPY – RBH / Wesley
 
 
 
 
 
            CONSULTANCY OUTREACH SERVICE (COS)
Community capacity to respond to the needs of people who have a life limiting illness, their caregivers and family is built through effective collaboration and partnerships
The Consultancy Outreach Service (COS) has a multidisciplinary team focus, with staff from the Palliative Care Service providing a model of care for the community.
The COS team includes:
  • Director of Palliative Care
  • Registrars from the PCU service
  • Community Liaison Nurse
  • Nurse Unit Manager
  • Clinical Psychologist
  • Volunteer Coordinator
  • Access to other allied health staff on request.
The aim is to provide a consultancy outreach service that offers support and advice for GP’s, domiciliary nursing agencies, aged care facilities, families and carers when specific palliative care problems and or symptoms require intervention. Patients who are unable to continue to attend clinical appointments due to deteriorating condition are able to be followed-up by their own GP in consultation with the Palliative Care Unit. Palliative care assessment is provided for non-oncological patients referred by their specialist consultant and a plan of care is developed for the terminal phase.
The objectives of this Service are:
  • Maintain and support the patient/client/resident requiring specialised palliative care within the community setting (home or Residential Aged Care Facility).
  • Assess needs of patient and develop a palliative care plan to address their individual requirements.
  • Advise and educate caregivers on holistic palliative management and intervention.
  • Increase the awareness for the caregivers and the community of the available palliative services and thus enable them to feel confident and involved in providing home based care.
  • Work in partnership with the GP, Nursing Agency, R ACF and other health providers in providing a model of care appropriate to the principles of Palliative Care.
  • Prevent inappropriate admissions and readmissions by early specialised intervention in consultation with the care givers.
On return to the Unit the Medical Officer will dictate a letter to the GP, Specialist and domiciliary agency outlining a plan of care and other information, with a copy for the medical record.  
PHONE SUPPORT
The Palliative Care inpatient unit provides a 24-hour, 7-day contact for GP’s, Domiciliary Nurses, patients, carers and family. 
CASE CONFERENCING
Case Conferences are conducted on a weekly basis. These conferences have been developed to have a multidisciplinary focus to service delivery to problem solve for complex issues.
 
The purpose of case conferences are to:
  • Utilise a multidisciplinary approach to case management
  • Focus on continuity of care for patients from hospital to community services
  • Establish a network for all service providers
  • Provide a community liaison between clinic/hospital and community service providers
  • Foster an understanding of roles of those involved in providing care
  • Ensure a more cohesive services for patients and carers
  • Identify gaps in service provision /funding
  • Offer support for all health care providers delivering palliative care
The meetings are chaired by the Nurse Unit Manager and in her absence by the Community Liaison Nurse for Palliative Care Service
Staff who attend the Case Conference include:
·         Domiciliary Nursing Staff from :-
* Blue Care Redcliffe
* Blue Care Caboolture
* Oz Care
* Karuna Hospice Service
·         Nursing staff from the unit when work load permits
·         Community Liaison Nurse for Palliative Care Services
·         Social Worker
·         Clinical Psychologist
·         Registrar and Resident
·         Medical Specialist, Palliative Care Service
·         Director of Oncology/Palliative Care
·         General Practitioners
·         Nurse Unit Manager of Service.
 
DISCHARGE - transfer HOME
Care, decision making and care planning are each based on a respect for the uniqueness of the patient, their caregivers and family. The patient, their caregivers and family’s needs and wishes are acknowledged and guide decision-making and care planning.
Care is coordinated to minimise the burden on patient, their caregivers and family.
 
A decision regarding future care and management is dependent upon individual patient needs as determined by the team. Factors that influence patient discharge are stability of condition and level of family support available. Those whose condition is stable can either be discharged home with family support or to an aged care facility if carers are unable to provide the level of care required. Those patients whose condition remains unstable on occasions remain as inpatients in the Palliative Care Unit.
Carers Kit:
An information package known as “A guide for supporting and caring at home” is available on discharge and provides Fact Sheets to help those involved in caring for their loved ones in the home with general information on some of the most common areas of concern. The kit supports the information provided by professional carers – PCU team, doctors and domiciliary nurses.
 
DOMICILIARY CARE & OTHER SERVICES
The Palliative Care Programme (PCP) operates under the principles and commitments of the Australian Health Care Agreement (2003-2008). 
PCP has made it possible for people with a terminal illness to access a range of services including:
·         Domiciliary Home Nursing Agencies
·         Home Care Assist
·         Hire of equipment
·         Consumables
·         Oxygen Concentrators
·         Nutritional Supplements
·         Allied Health Professionals – Occupational Therapists, Physiotherapists, Speech Pathologists
The Community Liaison Nurse (CLN) is to facilitate discharge needs and requirements determined by the Palliative Care Team’s plan of care
Palliative Care Service can access PCP funding to pay for short term hire of equipment such as shower chairs, wheelchairs, or hospital beds (for bedfast patients), if not able to be funded from other sources such as HACC. PCP Redcliffe will assess funding options for domiciliary agencies home visits, maximum of 1 hr per day. Assess funding options for domestic support and in home respite if required and not able to be funded through other sources. Assess funding options for dietary supplements if assessed by dietician as appropriate.
 
DECEASED – PCU / HOME
The unique needs of dying patients are considered, their comfort maximised and their dignity preserved.
 
Bereavement Grief Recovery Program
Formal mechanisms are in place to ensure that the patient, their caregivers and family have access to bereavement care, information and support services.
 
Within each family, individuals often have varying mechanisms to cope and survive with the loss of their loved one, and go through a normal grieving process. Some issues such as quality of death, relationship factors, social support and past experiences all contribute to the individual’s ability to cope. 
 
The Bereavement Risk Assessment Form assesses these issues and if two or more of these issues are identified as problematic a bereavement assessment is offered and often followed by individual bereavement counselling. 
The memorial service is conducted biannually by the staff from the PCU with volunteer support. Each memorial service is attended by approximately 100 – 120 families and friends. The service is non-denominational and held in the activities centre within the grounds of Redcliffe Hospital.   The participation of the Palliative Care Team provides family and friends of the deceased with an opportunity reunite with the team and if often seen as a way for families to move forward in the grieving process and closure for PCU staff and families.