Community Palliative Care Team What do we do?

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Community Palliative Care TeamWhat do we do?

• Dr Faith Cranfield
• Medical Lead, Community Palliative Care Team,
• St Francis Hospice

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Background

• Home care service established by daughters of
  charity in 1989 in a portacabin in Capuchin
  Friary in Raheny
• 1995 Inpatient unit (19 beds) opened SFH Raheny
• Two community teams East and West
• 2011 West team moved to new SFH Blanchardstown

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Catchment Area
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Who do we see?

• Cancer patients. All have incurable, progressive
  disease. Some continue palliative chemotherapy.
• Patients with MND
• Patients with other progressive fatal diseases
  terminal care patients receive full service.
  Others receive Palliative Medicine review to
  advise GP on symptom management, end of life
  decision-making.
• Children with life-limiting illnesses

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Location of care

• Home
• Nursing homes
• Homeless hostels
• Long term psychiatric hospitals
• Sheltered accommodation

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Team members

• Nurses 14 WTE CNS, including 1 WTE Management
  (0.5 East CNM, 0.5 West CNM)
• Medical director ¾ WTE
• 2 Registrars
• 2 Full-time Chaplains
• 2 WTE Social workers

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Activity 2012

• New referrals 974. New patients taken on 702.
• Referral source GP-204
• Beaumont-261
• Mater-228
• James Connolly-39
• Other 260
• Nursing visits 8557, Medical visits 693
• Deaths 701.
• Home-323,
• St Francis Hospice -626,
• other -390

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What The CPC Team Can Offer

• Specialist palliative care to patients
• Specialist palliative advice on patient
  management to professionals (GPs, nursing home
  staff)
• Support for patients family and professional
  carers
• 24 hour availability of telephone advice

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Working hours

• Mon- Fri normal working hours regular phone
  calls and visits
• 430-9pm Single nurse on call for North Dublin,
  can do home visit if necessary
• 9pm til 830 am Telephone advice via night nurses
  in Inpatient Unit in Raheny

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Accessing the service

• Referral received
• Next working day urgency for visit categorised
  based on need diagnosis and disease extent,
  prognosis, functional status, palliative care
  needs
• Waiting time variable urgent referrals warrant
  telephone contact to explain what the need is,
  identify if a visit is possible.
• First visit. Once seen, patients given contact
  details and can access 24 hour advice.

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Where do we fit in?

• GP remains primary carer
• Hospital care continues as appropriate
• Ongoing nursing telephone support and visits (NB
  all changes warrant review of effectiveness)
• PHN continues to review for pressure care needs,
  dressing needs, assessment and access to
  community physiotherapy/OT and to home carer
  support

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Input by CPC Team

• Visits by CNS frequency will depend on needs,
  patient preference, patients hospital
  appointments etc. Often weekly.
• Social work assessments/support
• At home/at hospice/Family meetings
• Chaplaincy visits at home
• Referral to Day care or Inpatient care as
  appropriate
• Volunteer Service

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Introduction of Hospice

• Often emotional for patient and family
• Breaking bad news
• Dying
• Anxiety re changing care/health
• Sense of abandonment
• Getting to know new team of health care
  professionals

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Challenges

• Establishing a good rapport trust
• Dealing with collusion
• Balancing patient and family needs
• Not meeting expectations e.g. hands on care
• Ensuring consistency amongst healthcare
  professionals information

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Assessment

• Symptom assessment physical. Clarifying
  medication.
• Addressing emotional / psychological / spiritual
  concerns
• Address family concerns
• Offer counselling / support
• Offer volunteers
• Daycare
• In-patient Care
• Liaise with other health care professionals

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Physical Symptoms

• Fatigue/Lack of energy/Weakness
• Anorexia
• Pain
• Dry mouth/sore mouth
• Nausea
• Early satiety
• Vomiting
• Constipation
• Diarrhoea
• Dyspnoea
• Cough
• Delirium
• Poor sleep
• Restlessness
• Falls

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Psychological Issues

• Loss of role
• Worry about family
• Fear of dying in pain
• The meaning of life
• Helplessness / being a burden
• Fear of death
• Loss of control
• Loss of dignity / privacy
• Financial difficulties
• Loss of future
• Anxiety
• Depression

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Psychological Issues for Family

• Grief and distress
• Exhaustion emotional and physical
• Coping with competing demands
• Their loved ones distressed
• Unfamilarity with death and dying
• Fear of what is to come
• Fear of being incompentent
• Fear of doing harm
• Disagreement/discord within family

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Spiritual distress

• Trying to make sense of things the Why? Of what
  is happening.
• Trying to find meaning
• Concerns about afterlife
• Prayer for support

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Decision making at home -in the event of physical
change

• What do we think is the cause?
• Information
• Access to tests. Mostly clinical assessment, /-
  CIT
• Is it reversible? Will treating the cause change
  the outcome? Does this warrant admission?
• What are the symptoms and how can we alleviate
  them?
• What does the patient want?
• In light of the change, is the situation
  sustainable?

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Medication

• Huge source of distress
• Poor swallow
• Weakness
• Drowsiness
• Under dosage
• Over dosage

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Nutrition

• Food important part of life
• - Shows love and concern
• - Sharing / nurturing
• Food becomes a burden
• Issue of starvation
• Natural process
• Burden and benefit

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Physical Environment

• House
• Stairs
• Downstairs Toilet
• Unsuitable accomodation
• Lack of equipment
• Lack of carers

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Example JD, 48

• JD, 48 y/o lady with metastatic non-small cell
  cancer. On chemotherapy. Separated working
  mother, self-employed. Two children.
• Seen at home. Angry, wary. Concerns raised re
  teenage daughter acting up, not aware of extent
  of disease. Planning for future care of
  daughters.
• Chemotherapy poorly tolerated vomiting, sepsis.
  Stopped.
• Recovers partially. Family meeting re illness.

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• Develops vomiting. Due to see solicitor at home
  that evening re will etc
• SC infusion antiemetic. GP review. Bloods by CIT
  hypercalcaemia and uraemia
• Glad of admission via day ward for fluids and
  bisphosphonate
• D/C home on SC infusion. Stopped after a few
  days.

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• Develops back pain known bony vertebral
  disease. Settles with opioids problematic
  constipation. Referred to radiation oncology.
  Receives thoracic XRT.
• Progressive weakens over weeks. Spending much of
  the day in bed. Worried re children. Expressing
  wish to die in hospice, but stay at home as long
  as manageable.

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• Back pain escalates over a week medications
  titrated with GP. Falls secondary to leg weakness
  and difficulty passing urine.
• Catheterised. Listed for admission to St Francis.
  No bed. Night-nurse organised.
• Bed becomes available. JD admitted to St Francis
  for terminal care. Dies after a two week
  admission.

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Difficulties For CPC Team Working In Other
Institutions

• Nursing home staff fill dual role professional
  carer / locum family member
• Homecare assumptions re nurse/carer familiarity
  with palliative drugs
• Difficulty meeting family members unlike home
• Changes in medication often slower to achieve
  than in the home

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Liaising and communicating

• With whom?
• The patient
• The family
• The GP
• The PHN
• Irish Cancer Society Night nursing service
• CIT
• The Hospital team
• A and E

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Anticipatory planning
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Misconceptions

• We visit at anytime
• We stay all the time
• We come when someone dies
• We come in an emergency
• We replace all other community services we come
  in and take over
• We have immediate access to beds
• We arrange everything
• We insist people know we are from the hospice

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Why do it?

• Achievement Enabling family to cope
• Enabling patient to die at home
• Improving someones subjective quality of life
  when time is short, the quality of each day can
  become very important
• Challenging
• Privilege

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Thank you for listening

• Any questions?