Background
On average just under 1200 people die each year aged 65 and above in Hounslow. Of those 50 percent access Specialist Palliative Care, while the rest rely on generic services to receive end of life care support (GPs, District Nurses, Adult Social Care and Hospitals). Data from 2007 until 2022 consistently shows that the majority of Hounslow’s end of life care (EoLC) patients died in hospital across all years.
This trend presents a challenge for acute providers, who have limited capacity to cater for end of life care patients with excessive unplanned hospital admissions, relatively longer length of stay, and a higher prevalence of in hospital deaths in the last year of life. Improving the outcomes and quality of care for patients, alongside enabling choice and better experience for patients at the end of their lives, as well as for their families and carers remains a local priority in Hounslow.
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This project aims to upskill frontline staff by increasing the knowledge/skills of health care professionals in identifying patients in their last years of life. So that they can have conversations that encourage patients, and their families to anticipate their care needs. This will help the management of End of Life Care to create a confident and competent workforce to care for those approaching the end of life.
A dedicated rapid response team which would take ownership of EoLC patients and comprising existing care input from WMUH/ICRS/DNs/ASC/CHC and SPC Team, but reframed with a view to realising a seamless and efficient support to patients and families experiencing crisis, so their needs are met with timely, hands-on personal and clinical care at home/community.
More patients with non-cancer conditions will be identified as approaching EoL with opportunity for sensitive, timely conversations being initiated with them and their families/carers: to discuss their condition and their likely prognosis/disease trajectory - which will then culminate into advance care planning/UCP, including a recorded cardiopulmonary resuscitation status to reflect wishes and feelings.
To enable care at home for EoLC patients who experience a crisis and whose needs cannot be met sufficiently quickly or fully by the existing services, including ICRS, DNs and GP/ARRS roles, by providing hands-on and clinical care under the leadership of Consultants in Palliative Medicine.
To deliver high quality, person-centred, compassionate care to EoLC patients, and their carers, in their homes or sheltered/Extra Care housing.
To provide sustained continuity of care, consistent and timely care planning, and coordination of care - to reflect patients’ clinical presentation and evolving needs.
To undertake the assessment, ordering, supply, review and safe use of equipment used to support nursing care within client’s homes.
To provide support to patients with non-specialist palliative care needs (patients identified to be on the EoLC register/WSIC who are not known to specialist palliative care team) supporting discharges from hospital and preventing avoidable readmissions.
To enhance EoLC at home through rapid intervention for crisis assessment, providing holistic assessment and care planning, symptom management and practical care to achieve the preferred place of death.