Susan is 78 years old and was diagnosed with dementia five years ago. She has a care plan and remains at home with the help of her husband and carer support three times a day from the council.
She currently receives general palliative care from her GP, community district nurses and the community mental health team.
She is now showing signs of entering the terminal phase of her illness and a review of her care plan by the generalist palliative care teams identifies additional complex needs including pain management and social factors.
She is referred to the adult community specialist palliative care team, part of the community specialist palliative care services in north west London to provide specialist support for Susan, her carers and the generalist palliative care team supporting her at home.
Current model of care |
Future model of care |
|
1. The adult community specialist palliative care team accept the referral but are unable to support Susan, her carers and general care teams at this time due to their current limited capacity and a need to prioritise more complex patients. |
1. Due to their increased hours of operation, the adult community specialist palliative care team are able to support Susan with her increasingly complex needs, her carers and the community teams providing general palliative care. Her care plan includes guidance on complex need management. |
|
2. Susan’s husband and the community teams providing generalist palliative care are unable to support her complex needs. As per her care plan Susan is taken to hospital when she deteriorates and needs extra care and support. |
2. At night when worried there is a 24/7 telephone advice line that Susan and her family can call so they are supported and provided with symptom management advice.
|
|
3. Susan is discharged and her care plan updated for increased social care support. The adult community specialist palliative care team ensure all available community support is now being accessed. The adult community specialist palliative care team visit and provide support for the complex care needs. The care plan includes a care preference for an inpatient hospice bed should her complex needs continue not to be met.
|
3. The adult community specialist palliative care services regularly review Susan, her carers and community teams changing needs. A multidisciplinary team (MDT) discussion and review of Susan’s care plan is arranged by the community palliative care team with Susan and those involved in her care. All agree Susan would be best cared for and supported in an enhanced end-of-life care bed as she does not need and does not meet the criteria for the most complex care and support that is provided in a hospice inpatient specialist palliative care bed. |
|
4. Susan, her carers and the community teams continue to struggle, and she is re-admitted to hospital as her deterioration was rapid and out of hours and the hospice was unable to admit her to an inpatient bed as they had to prioritise patients with more complex needs. |
4. Susan, her carers and those involved in her care were involved in the MDT and care plan. Susan is transferred to an enhanced end-of life bed. Where her long-term complex needs can be met.
|
|
5. Sadly, she passes away whilst awaiting a care home bed.
|
5. Susan was safe, comfortable and supported and her family were able to be with in her final days. |