Eli Silber

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Eli Silber

  1. 1. Eli Silber & Rachel Burman Consultant Neurologist, King’s College & Queen Elizabeth Hospitals Consultant in Palliative Care What will the new service look like?
  2. 2. The MS Team Addressing needs Diagnosis Rehabilitation GP rehabilitationist neurologist palliative care Disease control Symptom control Holistic approach
  3. 3. The MS Team Doctors GP Neurologist Rehab Psychiatrist Extended family/ friends Patient Family Nurses Ward / MS Continence District Therapy Physio, OT Speech / wheelchair Support organisations Work Social services/ professional carers
  4. 4. • 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
  5. 5. Why this setting? • Large, urban community • Diverse population, multicultural, social deprivation • Resources: neurology, palliative care, rehabilitation, nursing • Established teamwork
  6. 6. Aim of the service: To complement rather than duplicate the work of existing services
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. The Service: What will it look like? • Palliative care consultant • Palliative care nurse specialist • Psychosocial worker • Service co-ordinator • Administrator
  11. 11. 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
  12. 12. 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
  13. 13. The service: Referral criteria  We want to be as inclusive as possible Exclusive Inclusive
  14. 14. 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
  15. 15. Role of the service • Direct patient care • Liaison/Co-ordination – Link with other services • Education – Healthcare professionals – People with MS, carers & general public
  16. 16. 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
  17. 17. 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
  18. 18. Role of the service: Liaison • Link with other services • Coordination • Refer as appropriate • Worker - social services
  19. 19. 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
  20. 20. 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
  21. 21. Summary • Service configuration decided • JDs completed and appointments underway • Referral criteria established • Role of team – Direct care – Co-ordination and liaison – Education

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