Table 1 The organisation of care across the PHCT
PHCT member | Role with patients with palliative care needs | Timing and type of involvement | How is involvement initiated | Method of involvement |
|---|---|---|---|---|
GP | Provide general palliative care Assess patients’ needs Prescribe and manage medications Identify patients approaching end-of-life Care planning and anticipatory prescribing Manage and coordinate end-of-life care | Prior to diagnosis Continuous however during period where patient is receiving treatment may be intermittent until later stages | Patient presents to GP Referral from oncology | Appointments in surgery Home visits Occasional phone calls to patient and family |
District nurse | Provide general palliative care alongside GP, i.e.: management, coordination, and orchestration of services to enable good home care for dying patients Physical nursing needs, i.e.: wound management, continence care, catheter care, medication and syringe drivers | Last few weeks/days of life Often receive a referral soon after diagnosis of advanced cancer so will have initial meeting and then intermittent contact until later stages Continuous involvement in last few weeks/days of life | Referral from GP, oncologist, community matron, joint care manager, clinical nurse specialist | Always home visits Sometimes phone calls to patient and family |
Clinical nurse specialist | Provide specialist psychological and physical symptom management that | Can be from diagnosis of advanced cancer Intermittent | Referral from GP, district nurse, oncologist Complex needs that cannot be managed by the GP and district nurse | Always home visits Often phone calls to patient and family |
Community matron | Provide care and support to people with long-term chronic conditions to keep patients as healthy as possible and living independently Only involved if patient has a long-term chronic condition and cancer | From diagnosis of chronic condition Continuous | Referral from GP, district nurse, hospital team | Always home visits Sometimes phone calls to patient and family |
Joint care manager | Provide a service to adults aged 65 years and over with complex health and social care needs and adults of all ages who have been identified as eligible for NHS Continuing Healthcare funding Assess health and social care needs; plan, coordinate, and review services required | Discharge from hospital At home but at risk of being admitted to hospital/care home when don’t need to be In a Community Intermediate Care bed or at home with services to help you with personal care from Leeds Community Healthcare NHS Trust and need ongoing care Continuous | Referral from any health or social care professional | Home visits |
Complex and palliative continuing care service | Provide bespoke packages of care to fast-track patients with highly complex continuing care needs | Last few days of life Continuous | Referral from district nurse | Home visits |