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Eli Silber






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Eli Silber Eli Silber Presentation Transcript

  • Eli Silber & Rachel Burman Consultant Neurologist, King’s College & Queen Elizabeth Hospitals Consultant in Palliative Care What will the new service look like?
  • The MS Team Addressing needs Diagnosis Rehabilitation GP rehabilitationist neurologist palliative care Disease control Symptom control Holistic approach
  • The MS Team Doctors GP Neurologist Rehab Psychiatrist Extended family/ friends Nurses Ward / MS Continence District Therapy Physio, OT Speech / wheelchair Support organisations Work Social services/ professional carers Patient Family
  • Area covered by service
    • 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
  • 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 team Neurology Palliative care Rehabilitation MS nurses District 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