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End of life care - community support

Checked: 23-08-2022 by Vicky Ryan Next Review: 23-08-2022

Overview

This Remedy page aims to provide guidance on care for patients:

in the last year of life - please refer via Sirona SPA
rapidly deteriorating towards end of life - please refer via Sirona SPA and request that they are fast tracked.
in the last 2-4 weeks of life- please refer to St Peters Hospice

Referral - Sirona

Sirona provide end of life and palliative care support for people who are in their last year of life. Patients who are rapidly deteriorating can also be referred via this service and will be fast tracked. Patients in last 2-4 weeks of life can be referred to St Peters Hospice - see section below.

Referrals are via the Single Point of Access (SPA) – 0300 125 6789, seven days a week, or using the Sirona Community non-urgent SPA referral form. Patients will be assessed for the most appropriate care. Some examples of how Sirona support patient’s with their care needs are: administration of STAT doses for symptom control, further assessment for CHC Fast Track funding.

The people who provide End of Life Care fall into two main groups:

General care: Those who provide day-to-day care such as GPs, community or Marie Curie nurses, care workers and occupational therapists, as well as community companions and specialist charity groups.

Specialist care: Experts in palliative care such as consultants in palliative medicine and clinical nurse specialists

It is possible that people receiving End of Life Care may need both generalist and specialist care as their needs change.

Palliative care can be provided in different places including at home, in hospital, at a care home or a hospice. A team of professionals work together to assess care needs and those of family and friends.

Patients can be referred to a hospice if they have a life-limiting disease with associated problems that may be physical, psychological, social or spiritual in their origins.

Weston Hospice

Further information and referral process can be found here Weston Hospice

St Peter’s Hospice

Further information and referral process can be found here St Peter's Hospice

Hospice at Home (St Peter’s Hospice care service for people in the last two to four weeks of life)

St. Peter’s provide a specialist service for those people in the last two to four weeks of life.

Care visits will be offered between 08:00 and 20:00 with limited night cover available for patients in greatest need.

Referral Criteria:

Registered with a GP in BNSSG
18 or over
Actively deteriorating and have been assessed by a healthcare professional to be in the last two to four weeks of life
preferred place of death is ‘home’( advice and support will be provided to patients and staff in all care homes, but practical support will only be offered to Care Homes without Nursing unless exceptional circumstances).

Prioritisation of care will be to patients with:

Rapid deterioration
Unstable symptoms or complex symptoms that need high intensity of care
Limited or no package of care
High level of family support needed.

Referral – Hospice at Home

Referrals should be made on 0117 915 9508, 09:00 – 17:00, seven days a week.

Patients will be discharged if care is no longer needed.

If a patient requires care for longer than 4 weeks, onward referral will be made to continuing health care or social services home care where appropriate.

St Peter’s Hospice 24hr clinical advice line 0117 9159430

Anticipatory Prescribing

Please see the End of Life Care page for details of Anticipatory Prescribing

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.