Developments in End of

Life Care

John SheridanEnd of Life Care Clinical Educator

Tools available in the trust• AMBER care bundle

• Last Days of Life Care Plan

• Rapid Discharge Pathway

• Advance Care Planning

• DNACPR

• Advance Decisions to Refuse Treatment

Pre-pathway Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Identification of people in the last year of life

Discussions as the end of life approaches

Assessment, care planning and review

Co-ordination of care

Delivery of high quality of services in different settings

Care in the last days of life

Care after death

LCP

Rapid Discharge

AMBER Care Bundle

Advance Care Planning, including Preferred Priorities for Care

Electronic Palliative Care Co-ordination Systems

Key developments

End of Life Care Education

End of Life Care Education

Community Clinical Educator and Part

Time Acute Clinical Educator

Community Clinical Educator and Part

Time Acute Clinical Educator

Full Time Acute Clinical

Educator in End of Life Care

Full Time Acute Clinical

Educator in End of Life Care

End of Life added to trust

Stat-Mand Training

End of Life added to trust

Stat-Mand Training

CommunicationCommunication

Collaborative educational

working

Collaborative educational

workingRole Champions

Development Programme

Role Champions Development Programme

Development of best

practice tools

Development of best

practice tools

Multi-professional End of Life Education

Days

Multi-professional End of Life Education

Days

Location based

training

Location based

training

Transfer of Care ethos – not discharge

Transfer of Care ethos – not discharge

AMBER care bundle

For patients whose recovery is uncertain

• Care Plan recognised by all professionals in all settings:

community, hospital, hospice, ambulance

• Patient Held CarePlan

• End of Life Care Educational Days

• St. Catherine’s Hospice courses in communication skills.

• Guidance in relation to Advance Care Planning

• Role Champions development

• Network development – always someone to ask!

Opportunities

Can we make a difference• Change perceptions of ‘discharge’ into

‘transfer of care’

• Alerting as to admissions for susceptible patients

• Provide all MDT members, even extended members, with essential information

• Explicit information sharing – GP End of Life Register, Advance Care Plan, Preferences.

Importantly …….Unlike other aspects of care delivery and

treatment …….. We get only one opportunity to provide end of life care.

Getting it right first time is not an option

….. It is ESSENTIAL.

Contact for helpYork Acute• John Sheridan, End of Life Care Clinical

Educator, Ext 1106• Debbie Bayes, End of Life Care Clinical

Educator, Ext 1480• Specialist Palliative Care Team York Ext

5835• Out of Hours: St Leonard’s Hospice

01904 708553

Contact for help

Scarborough• Christine Wilson, End of Life Care

Clinical Educator, 01723 342446 • Specialist Palliative Care Team 01723

342446 • Out of Hours: “Pall Call”, St Catherine’s

Hospice, Scarborough: 01723 354506

Contact for help

Community• Becky Shaw, Community End of Life

Care Clinical Educator (07809) 519754• Specialist Palliative Care Team

Community York & Selby (01904) 724476

• Specialist Palliative Care Team Community Scarborough (01723) 356043