Eli Silber & Rachel BurmanConsultant Neurologist, King’s College & Queen Elizabeth Hospitals
Consultant in Palliative Care
What will the new service look like?
The MS TeamAddressing needs
Diagnosis RehabilitationGP
rehabilitationist
neurologist
palliative care
Disease control Symptom control
Holistic approach
The MS TeamDoctorsGPNeurologistRehabPsychiatrist
Extended family/ friends
Patient
FamilyNursesWard / MSContinenceDistrict
TherapyPhysio, OTSpeech / wheelchair
Support organisations
Work
Social services/ professional carers
• SE London - Area covered by old health authorities of LSL BBG
• Referrals from outside for patients with complex needs
• Large urban and suburban population• Includes some areas that are amongst the
most deprived in the country
Area covered by service
Why this setting?
• Large, urban community
• Diverse population, multicultural, social deprivation
• Resources: neurology, palliative care, rehabilitation, nursing
• Established teamwork
Aim of the service:
To complement rather than
duplicate the work of existing
services
Aims of the service• To provide a quality palliative care assessment• To provide specialist welfare benefits advice and and
bereavement support• Liase and act as a catalyst with local services, both
primary and specialist teams• To enable crisis prevention• To develop education and support to primary and
secondary care• To inform future research initiatives• To provide descriptors of good practice
The Service: Where will it be based?
• Physical base at King’s College Hospital
• Working alongside existing palliative care team
• Patients in neurology wards & rehabilitation unit
• Palliative care clinic linked to the regional MS clinic
The service: How will it work with other teams?
• Local MS services– MS nurses’ network – Neurologists in district general hospitals
• Palliative care network• Rehabilitation
– Units– Community & hospital based services
• GPs, district nurses• Other specialist nurses e.g. continence/tissue viability
The Service: What will it look like?
• Palliative care consultant
• Palliative care nurse specialist
• Psychosocial worker
• Service co-ordinator
• Administrator
The Service: Appointments Update
• Palliative care consultant – in post Jan 2003
• Psychosocial worker – in post Nov 2003
• Administrator – in post Jan 2003
• Palliative care nurse specialist
• Service co-ordinator
Members of the teamNeurologyPalliative careRehabilitation
MS nursesDistrict nurses
Hospices/ Nursing homes
Palliative care consultant
Palliative care nurse
Service co-ordinator
Social services+MS Society branch welfare officers
Psychosocial worker
The service: Referral criteria We want to be as inclusive as possible
Exclusive Inclusive
The service: Referral criteria
A palliative care assessment will be undertaken of anyone affected by MS or related condition if there are potential or existing problems with:
• Pain and symptom control • Psychosocial needs • End-of-life decisions• Terminal care
Role of the service
• Direct patient care
• Liaison/Co-ordination– Link with other services
• Education– Healthcare professionals – People with MS, carers & general public
Role of the service: Direct patient care• Hospital, home, institution • Work with existing carers/health professionals • Pain and symptom control
– Spasm
– Bladder/bowel
– Breathlessness
– Nausea
• Psychosocial needs
Role of the service: Direct patient care
• End-of-life decision making– Nutrition and hydration issues– Withdrawing and withholding treatment– Informed consent– Place of care
• Terminal care/dying
Role of the service: Liaison
• Link with other services
• Coordination
• Refer as appropriate
• Worker - social services
Role of the service: Education
• Healthcare professionals– Neurologists: training program for specialist
registrars, academic meetings– Regional GP postgraduate teaching– MS Nurses: monthly meetings– Meetings with rehab units/ palliative care– Physio/ OT/ Speech– Formal teaching tools for health professionals
Role of the service: Education
• People with MS, carers and the general public– Meetings with local branches of MS Society– Getting to grips with MS - course for people
with more advanced disease– Chat room discussions
Summary
• Service configuration decided
• JDs completed and appointments underway
• Referral criteria established
• Role of team– Direct care– Co-ordination and liaison– Education