End of Life Integrated Care Pathway
Welcome to the End of Life Integrated Care Pathway information page. Here you will find resources to help you with your clinical practice in delivering evidence based end of life care.
Summary of Pathway
In June 2008 the DH End of Life Care Strategy was published setting out a consistent message that a whole systems approach is needed to supporting patients in their last year of life. The care pathway involves the following steps:
- Identification of people approaching the end of life and initiating discussions about preferences for end of life care
- Care planning: assessing needs and preferences, agreeing a care plan to reflect these and reviewing these regularly
- Coordination of care
- Delivery of high quality services in all locations
- Management of the last days of life
- Care after death
- Support for carers, both during a person’s illness and after their death
In addition to this, the DH published the document “Quality Markers and Measures of End of Life Care” which sets out quality markers and indicators to support the delivery of improvements in End of Life care.
End of Life Integrated Care Pathway (ICP) – Derbyshire End of Life Guidance
In order to achieve this, an ICP group was established to oversee the development and the implementation of a Derbyshire End of Life Integrated Care Pathway. This was launched between December and February 2011 (see link below). The pathway sets out the importance of improving the use of the GSF (palliative care) registers in Primary Care. This will include working with the district nursing teams and/or other specialist teams e.g. Macmillan Nurses, Community Matrons, respiratory team etc to ensure that patients who are deemed to be in the last year of life have the relevant support to include advance care plans, documentation of the patient’s wishes such as DNACPR, EMAS forms and Right Care plans.
End of Life Group Members
- Steph Austin, Head of Clinical Quality (Chair), NHS Derby City, stephanie.austin@derbycitypct.nhs.uk
- Dr Maelie Swanwick, Palliative Care Consultant, Derby hospitals
- Dr Judy Parsons, GP Clinical Lead, Charnwood Surgery, jparsons@nhs.net
- Kathy Gorman, Macmillan Educator for nursing homes, NHS Derby City, Kathy.gorman@nhs.net
- Brendan Brown, Senior Nurse, Palliative Care, Derby hospitals
- Karen Bussooa, End of Life Project Manager, Derby hospitals
- Kathy Longden, Director for Nursing Treetops hospice
- Jackie Mason, Nurse Manager, Marie Curie
- Anthony Nichols, Oncology Programme Manager, NHS Derby City
- Sue Cox, Head of Community Nursing, Derby hospitals
Please contact us if you would like further help and support.
Useful Links
www.treetopshospice.org.uk - Treetops Hospice cares for adults in Derbyshire and Nottinghamshire with life-limiting illnesses such as cancer, motor neurone disease, multiple sclerosis, end stage heart disease and respiratory conditions. They also run a weekly specialised neurological day. Treetops Hospice provides Day Care in Risley, Hospice at Home, bereavement support for adults, children and families, a carers’ support group, complementary therapy, art therapy and a clinic in palliative medicine.
www.endoflifecare.nhs.uk - This is the main site for the national end of life care programme; it will provide you with a wealth of information around Advance Care Planning and Advance Decision to Refuse Treatment.
www.goldstandardsframework.org.uk/ - The main site for the Gold Standards Framework, within this site is information for all care settings.
www.adrtnhs.co.uk - Advance Decision to Refuse Treatment is an educational website; there are various teaching sessions you can work through.
www.macmillan.org.uk - Macmillan Cancer Support website provides a range of information to support patients with cancer.
www.dyingmatters.org - The Dying Matters coalition has been set up to encourage more open conversations about death and dying. There are a range of resources you can download on this website to help you start conversations with patients and their families about death and dying.