A number of Palliative Care professionals who attended our Palliative and End of Life Care Delivery Group on 8th November kindly shared some insights into how to better understand care co-ordination. You can find out more by looking at the slides from the day here.

Sandra Campbell (National Clinical Lead) presented on the importance of timely, sensitive conversations. Conversations should begin at the point of need by whoever is identifying the need / transition. The Palliative Care Identification Tools Comparator can be used to allow people to make more informed choices about their care and treatments when they have an irreversible illness. Significant conversations happen at the right time, in the right place with the right person.
Deans Buchanan (Consultant in Palliative Medicine, Lead Clinician) spoke about Health Transitions in Human Stories. Stories are very important to how we understand and communicate with one another. Most patients’ stories will have been interrupted by their illness and this can affect their response to treatment. The A, B, C, and D approach of dignity conserving care (Attitude, Behaviour, Compassion and Dialogue) is one method being tested to remind practitioners about the importance of caring for their patient.

Heather Edwards (Dementia Consultant, Care Inspectorate) gave a good overview of Bereavement. Heather highlighted the importance of preparation for death and the value of the care home staff in supporting families. Bereavement can cause an emotional toll on the staff as well as families but it’s important that we also support them as they are also grieving having developed relationships with the residents and their families.

Lynne Carmichael (Respite & Response Team Manager, Ayrshire Hospice) presented on carers and the Carers Support Needs Assessment Tool (CSNAT). One of the first barriers is many carers do not recognise themselves as a carer and often put their own needs to the side to care for a loved one. The CSNAT tool helps provide support for family members and carers of those with a life limiting condition.

Jo Hockley (RN PhD, Usher Institute, University of Edinburgh) presented on Care Co-ordination and Care Homes. As the population of over 80’s increases, they are becoming increasingly frail and more dependent, resulting in increased pressures on healthcare professionals supporting care homes. The main issues are:

– Lack of recognising the dying
– Lack of healthcare support to palliative care
– Lack of support staff

More work will need to be done around linking care homes into the system. This will hopefully be aided by a similar study to the Teaching Nursing Home pilot whereby the public/professional perception of care homes change, encouraging a career pathway in care homes for health and social care professionals, to help increase the workforce and establish more community engagement in care of frail older people.

Richard Meade (Head of Policy and Public Affairs, Marie Curie Scotland) offered an insight in Looking Beyond 2021 and thinking about the future. As the population is living longer, more people will be diagnosed with multi-morbidities, including dementia, frailty and cancer, and will therefore require increased palliative care. This in turn will increase the pressures on every care setting, the workforce, resources and the way we deliver care, and we must act now.

Anne Finnucane (Research Lead, Marie Curie Hospice Edinburgh) presented on the Key Information Summary (KIS) and a recent study undertaken on those who died with an advanced progressive condition in 2017 with a KIS in place. A KIS is a shared electronic clinical summary used to guide urgent care in the community and emergency hospital admission. It helps to communicate key elements and preferences from the person’s Anticipatory Care Plan (ACP) to help with future care needs.

Ali Guthrie (Learning & Development Advisor) discussed Personal Outcomes: towards a Shared Understanding. A Personal outcomes approach is focusing on what is important to people in their lives. They often relate to maintaining or improving wellbeing and feature in the National Health and Wellbeing Outcomes in the new Health and Social Care Standards.

For further information, please contact a member of our team at hcis.livingwell@nhs.net

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