Community specialist palliative care services

Specialist palliative care services are resources for healthcare professionals in all community care settings to access expert support for patients facing a life-threatening condition irrespective of diagnosis, in particular for:

  • management and monitoring of persistent and/or transient symptoms related to their palliative diagnosis
  • management of complex emotional or psychological issues related to their palliative diagnosis
  • management of complex social or family issues related to their palliative diagnosis
  • planning complex end of life care which goes beyond general palliative skills

It is important to recognise that the above are not mutually exclusive.

Aim of the service

The aim of the service is to ensure that patients with complex palliative care needs receive:

  • high quality symptom control assessments
  • psychological support
  • advice to meet their individual palliative care needs through direct patient assessment and working with co-providers

About the team

The team is comprised of experienced registered nurses who have additional specialist knowledge and experience and work to specialist palliative care competencies.

In addition to managing a clinical caseload within agreed boundaries and protocols they have a role within teaching, consultancy, and research.

The team work with other specialist palliative care providers to support all healthcare professionals provide holistic palliative care.

What we do

We work closely with your community health care team, particularly your GP and community nurses.

We work to 4 levels of intervention.

  1. Support given at this level involves no direct contact with the patient. It may involve a professional consultation between the referrer and the community specialist palliative care nurse on matters of symptom control and options of care.
  2. An assessment visit to a patient to provide added support to the professional, following which the patient is discharged.
  3. A short, planned episode of care is offered to the patient and family according to need.
  4. Care is offered on a longer-term basis where there are ongoing complex needs.

Referrals

If your needs require community specialist palliative care nurses involvement, your GP or hospital team can refer you.

Referrals to the community specialist palliative care nurse are appropriate when:

  • the patient has symptoms which are complex or rapidly changing
  • the patient has difficulty adjusting to palliative diagnosis or advancing disease
  • support may be required when decisions about palliative treatment options are being made

Referral process

  • This is not an emergency service.
  • The referral is made with the patient’s knowledge and consent.
  • Referrals will be accepted from healthcare professionals in writing.
  • Palliative care is shared with the Primary Care Team and/or Specialist Team.
  • Community specialist palliative care nurse works alongside GPs and hospital colleagues, who continue to have overall responsibility for their patients.
  • Referral to the service will normally result in telephone contact within 2 working days. This does not necessarily mean ongoing care will be given by the team. Assessment will guide the service offered. The patient may be referred on to other generalist and specialist services if appropriate.

For many patients in the late stages of their illness, palliative care needs can be fairly straightforward and met by the Primary Care Team (district nurse and GP).