Once a referral has been accepted, care is tailored to the changing needs of the patient with great emphasis being placed on proactive planning, flexibility and adaptability, and continual reassessment and monitoring. Early interventions are believed to prevent unnecessary admissions to the acute sector and the ethos involves delivering care as far as possible in the place of the patient’s choice.
REFERRAL CRITERIA FOR SPECIALIST PALLIATIVE CARE
Ealing and Hounslow Specialist Palliative Care Service
Specialist palliative care is the active total care offered to a patient with an incurable progressive illness. It also provides support to those close to the patient. The objective is a good death, with concentration during the patient’s life on quality of life and the alleviation of distressing psychological, spiritual, and physical symptoms. The impact of social circumstances is also taken into account.
Ealing and Hounslow Specialist Palliative Care Service provides care to those in need of it in the boroughs of Ealing and Hounslow and includes residents from adjoining boroughs registered with Ealing and Hounslow GPs. We work within a multidisciplinary and interdisciplinary framework.
Care provision is based on need and not on diagnosis or stage of disease
The service operates as a continuum across:
- Inpatient hospice care
- Day Hospice
- Community care
- Acute sector hospital support at West Middlesex University Hospital and Ealing Hospital
2. GENERAL REFERRAL INFORMATION
- Any healthcare professional can refer to the Specialist Palliative Care Team but must have the agreement of the GP and the patient and/or carer.
- Decisions about appropriate intervention are based on comprehensive and detailed information about the patient and this is expected at the time of referral.
- Patients and carers are free to initiate referrals themselves.
- The service uses the West London Supportive and Palliative Care Network standard referral forms (which can be obtained through our Referrals Officer)
- Our Referrals Officer processes all referrals and can be reached on the following numbers:
Office phone number: 020 8967 5758
Office fax: 020 8967 5756
3. INPATIENT UNIT REFERRALS
3.1 General considerations
Referrals are presented at the daily (weekdays) referral meeting which is run by consultant staff.
For patients referred from the community, the Community Specialist Palliative Care Nurse will communicate the decision about admission to the primary care team.
A response form is sent to referring hospitals to let the referring personnel know when a patient has been placed on the waiting list.
For referrals to be presented at the daily referral meetings, they must be with the Referrals Officer by 9:00 am, Monday to Friday.
Places are offered on the basis of need, not diagnosis.
Admissions to the Hospice are influenced by bed availability but we would hope to admit home care patients as soon as possible and those referred from acute hospitals within the week. PLEASE NOTE THAT THIS IS NOT ALWAYS POSSIBLE BECAUSE OF THE PRESSURE ON OUR 15 BEDS.
It is usual that the period of inpatient stay does not exceed 2 weeks, although the needs of individual patients are continually reassessed.
It is not infrequent that a patient’s admission category changes during admission. For example someone admitted for assessment/review may turn out to have significant symptom control difficulties and this would alter the course of stay.
There are three categories of inpatient care:
- Terminal care
- Assessment and symptom control
a) Terminal Care
This is for patients who may be in the active process of dying. Since predicting death is not an exact science, and, whilst these admissions are not expected to exceed two or three weeks, individual patient needs or circumstances differ and frequently change.
b) Assessment and Symptom control
Admission is available at any stage of a disease trajectory where a patient’s symptoms and/or circumstances are sufficiently complex or unstable to need a stay on the unit for full interdisciplinary assessment and intervention. Typically the stay does not exceed a fortnight.
c) Assessment/review care
Assessment/review care is offered as part of their overall package only to patients who have established specialist palliative care needs and are in receipt of specialist support in the community.
Admissions for assessment/review care are scheduled in advance.
We do not usually accept requests for assessment/review admissions directly from acute hospital stays.
We normally offer one week every three months or two weeks every six months. Scheduled admissions run from Monday to Monday.
ADMISSIONS DURING THE SCHOOL HOLIDAYS IN THE SUMMER ARE FOR A WEEK AT A TIME ONLY
At the end of an assessment/review admission, the patient is expected to return home supported by the appropriate package of care. The package is routinely reviewed at each assessment/review.
In circumstances where a patient’s condition changes during an assessment/review, he or she may be reallocated to either of the other admission categories.
All discharges from the Inpatient Unit are conducted in accordance with the specialist palliative care discharge protocol. Discharges are only affected when the multidisciplinary team is satisfied that the needs of the patient can be adequately provided for in a non-specialist environment, and the appropriate arrangements for care and equipment provision have been made.
4. DAY HOSPICE
Day Hospice is offered to patients who are known to the service as a result of having specialist palliative care needs.
Patients are suitable for Day Hospice referral if they could be expected to benefit from the following:
- Maintenance of psychological and social functioning
- Assessment/review from social isolation
- An ‘early warning system’ to prevent crises at home
- The opportunity to be involved in creative activities which stimulate interest and participation, helping to encourage self esteem
- Peer support from others in a similar situation
- The opportunity to be ‘phased in’ to the palliative care service
Patients who are not suitable for Day Hospice care are those:
- with a current history of mental health problems
- whose main needs are rehabilitative rather than palliative e.g. following a stroke
- with advanced dementia
- who are confused as a result of cerebral involvement from their disease
An initial period of 6 sessions in Day Hospice is planned when patients are first referred. When this time has elapsed, further assessments are performed to ensure that continued attendance at Day Hospice is in the patient’s best interest. If this is not the case, the patient will be discharged back to the care of the Community Specialist Palliative Care Team.
5. COMMUNITY PATIENTS
5.1 General considerations:
The Community Specialist Palliative Care Team offers support, advice and expertise to primary health care professionals, to other agencies and directly to the patient and his or her family and carers.
The services we offer include:
- informal discussion and advice
- joint visits and consultations
- debriefing on difficult cases
- case-based analysis and teaching
- formal teaching sessions
- out of hours advice and support
The criteria for which patients can be referred are:
- Complex pain and symptom management
- Psychosocial support
- End of life care
- Liaison between primary care and specialist services
- Bereavement support
5.2 Routine referrals
These are triaged at the daily community referral meeting
A response would be expected on the next working day.
A referral will be considered urgent if there is evident distress in a patient, his or her carers or the professionals involved in the situation. These would include:
- Unexpected clinical crises e.g. rapid deterioration
- distressing uncontrolled symptoms
- family crisis
- uncertain and unstable clinical situation
A response would be expected within the same working day.
5.3 Discharges from the Community Team
Some patients are discharged from Community Team follow up if it is agreed that they no longer have specialist palliative care needs. In such cases, the Primary Care Team will be informed that ongoing monitoring by the Specialist Palliative Care Service will cease but re-referral can always be reconsidered at a later date if our involvement once again becomes relevant.
The Service offers no formal outpatient clinic model. However, Consultant level staff are available for outpatient consultations which take place on the Hospice site. This facility is offered on a pro re rata basis, with follow up appointments being arranged as necessary.
Outpatient consultations enable us to:
- give a specialist opinion on individual patients who may need
- a single assessment to guide a GP or consultant colleague or
- intermittent contact
- specialist palliative care drugs not readily available on FP10
- review and assess complex symptom management for the Community Specialist Nurses
- perform certain procedures and investigations
- offer acupuncture for myofascial pain syndromes
The initial referrals can be made through our Referrals Office on the above number. In some cases the referring professional may be contacted directly to discuss the case before the patient is seen. Follow up visits are normally agreed between the attending physician and the patient or carer.
7. HOSPITAL SUPPORT
7.1 General information
Hospital support is provided to inpatients at Ealing Hospital and West Middlesex University Hospital by the hospital palliative care Clinical Nurse Specialists.
The nurses are supported at weekly multidisciplinary meetings which are also attended by a specialist palliative care consultant. The latter will visit any ward based patients who require this level of input, as advised by the CNS.
Referrals can be made to the Palliative Care Clinical Nurse Specialists by any member of the hospital staff.
For Ealing Hospital Trust, the palliative CNS can be accessed via the switchboard at Ealing Hospital NHS Trust and works from 08.30 – 16.30 on weekdays.
At West Middlesex University Hospital Trust, the palliative care team can be accessed via the main switchboard and is available between 08.30 and 16.30 on weekdays.
Normally patients will be reviewed as to appropriateness within 1 working day.
All hospital staff at West Middlesex and Ealing Hospital have access to the out of hours palliative advice service which is reached by calling the ward at Meadow House on 020 8967 5597.
The following patients would be considered suitable:
- Patients with complex symptom control problems, particularly where the clinical situation is unstable
- Patients with a terminal diagnosis requiring psychosocial support
- Those who may need complex discharge planning in the context of a terminal illness
- Patients who are expected to die during their hospital admission and require active management of the dying process
- Cases where there are issues concerning the withdrawal of active treatment
- Patients for whom transfer to the inpatient hospice environment may be appropriate
We would under certain circumstances discontinue specialist input if the patient’s condition becomes very stable, or if the reason for the initial referral is no longer relevant. Under these circumstances, re-referral can always be initiated if necessary.
Geraldine Nevin (Lead Nurse), Emma Thompson (Consultant) and Jane Cowap (Lead Clinician) Treena Saini (Consultant)
Ealing and Hounslow Specialist Palliative Care Service Dec 2013