The document provides guidance for hostel staff on delivering high quality end of life care to homeless individuals. It outlines 6 steps in an end of life care pathway, from initiating discussions as end approaches to care after death. The guidance emphasizes identifying triggers for discussions, developing care plans, coordinating services, and treating individuals with dignity and respect regardless of setting.
23 September 2010 - National End of Life Care Programme
This guide is principally for professionals working in health and social care and allied professions. Its main aim is to provide links to information sources, resources and good practice in end of life care (EoLC) for people with dementia, particularly for those who work with people with dementia who are not EoLC experts and EoLC experts who are not particularly knowledgeable about dementia.
While the document is not principally written for patients and carers, some of the information will be relevant to them.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
right conversations, right people, right time
27 January 2011 - National End of Life Care Programme
This is the final report from the communication skills pilot project, which funded pilot sites to explore training need, provision, strategy and sustainability. Service users and other partners also contributed to the project.
It celebrates the NEoLCP's work in equipping our workforce with the confidence and competence to respectfully and compassionately care for individuals and their families towards the end of life.
The pilots carried out a training needs analysis, reviewed existing provision and benchmarked it against national competences. They then used a needs-based approach to develop new training plans. This report highlights the project's findings and identifies key messages.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
23 September 2010 - National End of Life Care Programme
This guide is principally for professionals working in health and social care and allied professions. Its main aim is to provide links to information sources, resources and good practice in end of life care (EoLC) for people with dementia, particularly for those who work with people with dementia who are not EoLC experts and EoLC experts who are not particularly knowledgeable about dementia.
While the document is not principally written for patients and carers, some of the information will be relevant to them.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
right conversations, right people, right time
27 January 2011 - National End of Life Care Programme
This is the final report from the communication skills pilot project, which funded pilot sites to explore training need, provision, strategy and sustainability. Service users and other partners also contributed to the project.
It celebrates the NEoLCP's work in equipping our workforce with the confidence and competence to respectfully and compassionately care for individuals and their families towards the end of life.
The pilots carried out a training needs analysis, reviewed existing provision and benchmarked it against national competences. They then used a needs-based approach to develop new training plans. This report highlights the project's findings and identifies key messages.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
Living as Well as you Can for As Long as you CanBCCPA
Sit down buffet breakfast featuring keynote speaker Dr. Romayne Gallagher, Head Division of Palliative Care, Department of Family & Community Medicine, Providence Health Care; Clinical Professor, Division of Palliative Care, UBC
Personal Health Budgets and Continuing HealthcareMS Trust
This presentation by Gill Ruecroft, Commissioning Manager, provides an overview of Personal Health Budgets (PHBs) and demonstrates the effectiveness of PHBs through case studies.
It was presented at the MS Trust Annual Conference in November 2014.
21 June 2012 - National End of Life Care Programme
This guide, produced with support from The College of Social Work, raises key questions about social work involvement in the last year of a person's life.
Following the nationally-recognised six-step end of life care pathway, the guide includes key issues and actions for social workers and their managers, top tips, reflective questions, examples of good practice and anonymised case studies. Key messages emphasise that:
Social workers have the skills to work with people approaching the end of life and their families and carers
Social work support may begin at any stage in the end of life care pathway and often the social worker may be the first professional to recognise that the person is in need of end of life care
It is important for managers to support their social workers in engaging with the end of life care needs of service users; this includes facilitating access to end of life care training, resources and systems
Specialist palliative care social workers can offer a valuable resource to social workers in other settings through consultation, education and training, as well as receiving referrals as appropriate.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
A care home 'is' someone's home, one day it could be yours too … best practice in end of life care in care homes. Presentation from Eleanor Sherwen, Elaine Owen and Caroline Flynn from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Enhancing Efficiency and Best Outcomes in Community Care: CBI’s Transitional ...BCCPA
In October 2016, CBI opened its first transitional and residential care in Burnaby, BC. Led by a multidisciplinary team that includes nurses, physiotherapists, occupational therapists, social workers, speech therapists, dieticians, behavioural interventionists and personal support workers, the facility provides specialized health care to support patients leaving hospital who are not yet able to return to their own home. This unique service also decreases hospital length-of-stay, admission and readmission to the hospital and wait times in emergency rooms. Join us and learn more about how our Transitional Care model helped patients, hospitals and funders to achieve excellent health and financial outcomes.
Presented by: Poonam Jassi, Director of Operations BC, CBI Health Group
Our goal is to cover the wide areas of overlap and similarities between the two disciplines, and to also make the differences between the two clearer for you.
Social care information packs
This is a series of short information sheets and matching slide sets about how social care staff can support people with learning disabilities to have better access to health services. They provide an introduction to each area and links to where further information and useful resources can be found.
Social care information packs
This is a series of short information sheets and matching slide sets about how social care staff can support people with learning disabilities to have better access to health services. They provide an introduction to each area and links to where further information and useful resources can be found.
Living as Well as you Can for As Long as you CanBCCPA
Sit down buffet breakfast featuring keynote speaker Dr. Romayne Gallagher, Head Division of Palliative Care, Department of Family & Community Medicine, Providence Health Care; Clinical Professor, Division of Palliative Care, UBC
Personal Health Budgets and Continuing HealthcareMS Trust
This presentation by Gill Ruecroft, Commissioning Manager, provides an overview of Personal Health Budgets (PHBs) and demonstrates the effectiveness of PHBs through case studies.
It was presented at the MS Trust Annual Conference in November 2014.
21 June 2012 - National End of Life Care Programme
This guide, produced with support from The College of Social Work, raises key questions about social work involvement in the last year of a person's life.
Following the nationally-recognised six-step end of life care pathway, the guide includes key issues and actions for social workers and their managers, top tips, reflective questions, examples of good practice and anonymised case studies. Key messages emphasise that:
Social workers have the skills to work with people approaching the end of life and their families and carers
Social work support may begin at any stage in the end of life care pathway and often the social worker may be the first professional to recognise that the person is in need of end of life care
It is important for managers to support their social workers in engaging with the end of life care needs of service users; this includes facilitating access to end of life care training, resources and systems
Specialist palliative care social workers can offer a valuable resource to social workers in other settings through consultation, education and training, as well as receiving referrals as appropriate.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
A care home 'is' someone's home, one day it could be yours too … best practice in end of life care in care homes. Presentation from Eleanor Sherwen, Elaine Owen and Caroline Flynn from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
Enhancing Efficiency and Best Outcomes in Community Care: CBI’s Transitional ...BCCPA
In October 2016, CBI opened its first transitional and residential care in Burnaby, BC. Led by a multidisciplinary team that includes nurses, physiotherapists, occupational therapists, social workers, speech therapists, dieticians, behavioural interventionists and personal support workers, the facility provides specialized health care to support patients leaving hospital who are not yet able to return to their own home. This unique service also decreases hospital length-of-stay, admission and readmission to the hospital and wait times in emergency rooms. Join us and learn more about how our Transitional Care model helped patients, hospitals and funders to achieve excellent health and financial outcomes.
Presented by: Poonam Jassi, Director of Operations BC, CBI Health Group
Our goal is to cover the wide areas of overlap and similarities between the two disciplines, and to also make the differences between the two clearer for you.
Social care information packs
This is a series of short information sheets and matching slide sets about how social care staff can support people with learning disabilities to have better access to health services. They provide an introduction to each area and links to where further information and useful resources can be found.
Social care information packs
This is a series of short information sheets and matching slide sets about how social care staff can support people with learning disabilities to have better access to health services. They provide an introduction to each area and links to where further information and useful resources can be found.
The route to success in end of life care - achieving quality in care homes
16 June 2010 - National End of Life Care Programme
This guide follows the six steps of the pathway laid out in the national End of Life Care Strategy.
It includes questions staff and managers should ask about end of life care provided in their care home and the employees' role in that care.
The guide is linked to the End of Life Care Strategy Quality Markers.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
The London Assembly Health Committee has investigated the quality of care people receive at the end of their life. Does good end of life care depend on your age, whether you live alone, your diagnosis or economic status? Read the digital report's finding and recommendations.
Explores palliative and end of life care. Outlines advance care planning and provides information about planning ahead to include using advance healthcare directives
Palliative care white paper for RegenceErin Codazzi
Writing this white paper for Regence was a humbling experience, connecting directly with the doctors, nurses, nonprofits and industry influencers dedicated to elevating the awareness for palliative care. It's an important topic and one every one of us should start talking about, as daunting as it may be. Grateful to the team at Regence for letting me dig deep on this one. Read the press release: http://news.regence.com/releases/regence-blueshield-releases-findings-on-the-importance-of-a-holistic-approach-to-palliative-care
Challenges for economic evaluation when doing research with people with learn...cheweb1
Challenges for economic evaluation when doing research with people with learning disabilities - Claire Hulme, Professor of Health Economics, University of Leeds
Annotated Bibliography
Kimberly Phillips
Colorado Technical University
Abstract
Nursing home or home care are the options loved ones of dementia suffers are faced with. For Comment by user: sufferers
some, nursing homes are not an option because of fear. Many dementias suffer are cared for in his or her place of residence. This paper is going to examine some pros and cons of caring for loved ones who has dementia at home. It is also going to review ways that home-dwelling dementia patients caregivers can receive the support he or she may need to provide good quality care to their loved ones. Comment by user: Keep in mind, you are in a Doctorate of Management Program and your paper has to be related to Management. You must start thinking about how you are going to manage something.
Keywords: Elderly, geriatric, home care, dementia
Running head: ANNOTATED BIBLIOGRAPHY 1
ANNOTATED BIBLIOGRAPHY 2
Annotated Bibliography or Replace with Your Title
This is review of the papers I am going to use to help me focus on my topic. I am interested in keeping elderly people who suffers from dementia in his or her own place of residence than being admitted into a nursing home. Comment by user: This annotated bibliography is a review of sources being used to support my topic of interest. Comment by user: With your dissertation, you aren’t trying to solve anything.
Annotation # 1
Bantry White, E., & Montgomery, P. (2015). Dementia, walking outdoors and getting lost:
incidence, risk factors and consequences from dementia-related police missing-person
reports. Aging & Mental Health, 19(3), 224-230. doi:10.1080/13607863.2014.924091
Author’s Abstract
“Objectives: To estimate incidence, identify consequences and potential risk factors for harm in people with dementia who got lost in one UK policing region. Methods: In a retrospective observational study, data were extracted from missing-person records over a four-year period in one UK policing region (population of 2.1 million). Results: Two hundred and eighty-one incidents of getting lost were identified. Incidence of getting lost was estimated at 0.5% of the regional dementia population. Fifty-nine percent of reports came from domestic settings, 29% from care homes/hospitals, and 12% on excursions from home. Five percent (n= 15) sustained significant harm, including two deaths. Average age was 78 years (SD 8.3). Harm was associated with older age (mean difference 6.16 years, CI 1.86 to 10.46,p= 0.005,t= 2.82), length of time missing (Mdn time 2.48 hours; IQR 0.97 to 9.45,p= 0.02), and season (9% winter, 2% summer,p= 0.006). The length of time missing increased with delays in reporting to police (r= 0.15,p= 0.018), getting lost at night (Mdn time 1.70 hours, IQR 0.52–3.32,p= 0.028), driving themselves (Mdn time 2.45 hours, IQR 0.42–2.00,p= 0.001), and using public transport (Mdn 1.78 hours, IQR 1.07–3.92,p= 0.001). Conclusion: Incidence in this study suggests getting lost is a low-fr.
Early identification of those who are
approaching the end of their life will enable
more people to be supported in living well
before they die, ensuring that they have access
to appropriate care and support services.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
The route to success in end of life care - achieving quality for people with learning disabilities
28 February 2011 - National End of Life Care Programme
This publication aims to provide a practical guide which supports anyone caring for people with learning disabilities to ensure that those who may be in the last months of their life receive high quality end of life care.
It may also be useful to health or social care professionals who come into contact with people with learning disabilities in clarifying what measures need to be taken to ensure that they can access appropriate care.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
Reply 1There is not a single specific point in an illness, whe.docxcarlt4
Reply 1
There is not a single specific point in an illness, when end-of-life care begins. It depends on an individual and progression of their illness. At stage of terminal illness, despite best care, attention and treatment. If your loved one comes to the end of their life, the focus would be to make them comfortable as possible. Depending on nature of disease, the final stage period may last weeks, months, or several years. This time palliative care help to control pain, other symptoms, shortness of breath, hospice care, support emotionally and spiritually to both patients and their families.
Dying at home a major challenge; a severe shortage of professional home care giver, the expense of hiring-quality help, the difficulties of pulling together a community of family and friend for 24-hour care, medical advances of recent decades. Depending on what is available near you, some hospice offering include in-home care, but Medicare has limited coverage. Families prefer alternatives that are expensive or require endless hours. The options come in mind is nursing homes, 5 thousands-10 thousands/month. Though, at home you have the smell of cooking, grand children coming, is more comfortable for elders. Some elders love their life at home but need more service at home. Dying at home is realistic?
Sandi
Hebley,
an educator at faith presbyterian hospice in Dallas, shares her visit to japan and New Zealand, observed and found out that the resources at home are larger more extensive. In Great Britain, hospice movement started in 1960. Hospice advocate,
Cicely
Saunders
placed teams that went to home with case manager several nurses. That setup made a huge difference there.
To support patient regarding end-of-life. I like the POLST paradigm, a framework to help and guide a conversation about what kind of care a patient wants when future health crisis occurs. Some changes in health care system can improve care of individual with progressive illness. For example, we should broaden end-of-life to mean the last years of life, by developing a health care pathway for chronically ill and declining people who are at their last years of life as described in “Medicaring” white paper by Dr. Jonne Lynn. The UK has developed a “Gold standard Framework” along similar lines. We can learn their work by studying their approach.
Furthermore nurse can support by
communicating
with members to manage family involvement t, by
focusing on values
by knowing wishes,
help to seek financial and legal advice
such as living will, attorney,
address family conflicts
by involving social worker or hospice specialist,
preparing early
by hospice and palliative care services.
Reference
Bill. W. (2018). How realistic is dying at home. The difference between where American would prefer to die and where they do?
Grand Canyon University (2018). Health assessment
: foundation of effective practice.
Health assessment of aging adult. Retrieved
from http//
www.gcumedia.c.
The route to success in end of life care - achieving quality in domiciliary care
26 February 2011 - National End of Life Care Programme
This guide has been developed by the National End of Life Care Programme in conjunction with a range of organisations working with people receiving domiciliary services at home, as part of its route to success series.
It is intended to be a practical tool offering advice on what domiciliary organisations and their staff can do as well as how and when to access specialist help.
Publication by the National End of Life Programme which became part of NHS Improving Quality in May 2013
Similar to End of life care - achieving quality in hostels and for homeless people (20)
This Guide for Executives is aimed at senior healthcare leaders. It provides 31 practical tips for leaders
who want to contribute positively to the culture for innovation in their organisations and systems.
A more in-depth practitioners guide, Creating the Culture for Innovation, provides much more
detailed advice and guidance, a host of additional examples, and information about an online staff
survey that can be used to assess, benchmark and understand the culture for innovation.
The Sustainability Model is a diagnostic tool that will identify strengths and
weaknesses in your implementation plan and predict the likelihood of sustainability
for your improvement initiative.
The Sustainability Guide provides practical advice on how you might increase the
likelihood of sustainability for your improvement initiative.
Pathways to Success: a self-improvement toolkit Focus on normal birth and reducing Caesarean section rates
Caesarean section (CS) has an important role in ensuring safe maternity care. How can we make
sure that every Caesarean is appropriate, effective and efficient?
The NHS Institute for Innovation and Improvement is working with NHS clinical staff to promote best practice in achieving low CS rates while maintaining safe outcomes for mothers and babies.
This toolkit is designed to help maternity services review and assess their current practice in promoting normal birth and reducing CS rates. The toolkit also provides practical techniques to support sustainable changes in maternity services.
A practical, introductory guide to thinking differently. It is not a comprehensive blueprint nor is it designed to make you an expert in thinking. But it will get you started on
a journey of thinking differently, and therefore doing things differently, that we hope continues well into
your future.
We have selected concepts and thinking tools that have proven their value, ease, and applicability in a
variety of industries and in over five years of experience with front line teams in various NHS organisations.
We’ll provide you with just enough background theory to help you see why the various thinking tools ask
you to do certain things that might seem a bit odd at first. But the emphasis here is not on dry theory or
abstract concepts. Rather, it is on developing new thinking that leads to new ways of doing.
If you are involved in treating patients, managing and/or improving health services or
managing or training those that do, you will understand the importance of providing the
best care possible for all our patients.
Great progress has been made in improving service standards and access and in reducing
waiting times, but there is still some way to go to ensure consistently high standards of
patient care across the NHS.
It is clear that we need to ensure we are getting it right first time, which means better care
and better value through the reduction of waste and errors and the prioritisation of effective
treatments. Quality, innovation, productivity and prevention (QIPP) is the mechanism through
which we can achieve this.
QIPP is about creating an environment in which change and improvement can flourish; it
is about leading differently and in a way that fosters a culture of innovation; and it is
about providing staff with the tools, techniques and support that will enable them to take
ownership of improving quality of care.
The Handbook of Quality and Service Improvement Tools from the NHS Institute brings
together a collection of proven tools, theories and techniques to help NHS staff design and
implement quality improvement projects that do not compromise on the quality and safety of
patient care but rather enhance the patient experience.
The ebd approach (experience based design) is a method of designing better experiences for patients, carers and staff. The approach captures the experiences of those involved in healthcare services. It involves looking at the care journey
and in addition the emotional journey people
experience when they come into contact with a particular pathway or part of the service. Staff work together with patients and carers to firstly understand these experiences and then to improve them.
This guide is an introduction to the ebd approach (experience based design).
This guide and toolkit has been produced as
a result of work that the NHS Institute for
Innovation and Improvement has undertaken in collaboration with NHS organisations and external agencies, using the experience of patients, carers and staff to design better
healthcare services.
This document is one of a series of documents that was produced by the NHS Institute for Innovation and Improvement as part of the High Volume Care programme.
Produced by the Delivering Quality and Value Team, the aim of the Focus on series was to help local health communities and organisations improve the quality
and value of the care they deliver
Support Sheet 18: PPC
This support sheet provides a description of Preferred Priorities for Care, a tool for the discussion and recording of end of life care wishes and preferences.
Support Sheet 15: Enhancing the Healing Environment
This support sheet outlines key design principles for end of life care environments and provides tips for managing an environmental improvement project
Support Sheet 14: Using the NHS Continuing Health Care Fast Track Pathway Tool
This support sheet provides answers to frequently asked questions about the NHS Continuing Health Care Fast Track Pathway Tool.
Support Sheet 13: Decisions made in a person's 'Best Interests'
This support sheet outlines the process for making decisions on behalf of someone who lacks capacity.
Support Sheet 12: Mental Capacity Act (2005)
This support sheet outlines the main provisions of the Mental Capacity Act the four tests essential for assessing capacity
Support Sheet 11: Quality Markers for Acute Hospitals
This support sheet outlines the quality markers by which acute hospitals can measure the standard of end of life care they provide.
Support Sheet 7: Models/Tools of Delivery
This support sheet outlines the key elements of
Advance Care Planning (ACP)
Gold Standards Framework (GSF)
Liverpool Care Pathway (LCP)
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
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Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
End of life care - achieving quality in hostels and for homeless people
1. End of life care
Achieving quality in hostels
and for homeless people a route to success
2. A practical guide to implementing high quality end
of life care for homeless people in our communities
3. Contents
3
Introduction
4
Background
5
Aim of the guide
6
Key considerations for delivery of end of life care
7
When to start thinking about end of life care
8
End of life care pathway
9
Step 1: Discussions as the end of life approaches
12 Step 2: Assessment, care planning and review
15 Step 3: Co-ordination of care
18 Step 4: Delivery of high quality care in different settings
21 Step 5: Care in the last days of life
24 Step 6: Care after death
27 Next steps
29 Useful resources
31 Appendix 1: Quality markers for end of life care
32 Appendix 2: Support sheet Mental Capacity Act
34 Appendix 3: St Mungo’s palliative care service pathway
4. Introduction
According to the 2008 End of life care strategy, high quality end of life care
“should be available wherever the person may be: at home, in a care home,
in hospital, in a hospice or elsewhere. Implementation of this strategy should
enhance choice, quality, equality and value for money.” (End of life care strategy,
Department of Health, 2008)
This strategy poses particular challenges in
relation to homeless people, who are often
described as a hidden population. Homeless
people are often overlooked when policies
are developed, and often not engaged with
service development.
Photo courtesy of St Mungo’s homeless charity
3
So the complexity of life for homeless people is
often mirrored by complexities around end of
life care.
5. Background
It is estimated that in England around 40,500
people are in the hostel system at any one
time and that over the course of a year
approximately 100,000 individuals move in
and out of it. For some the lack of a settled
home may be temporary and quickly resolved.
Others may be homeless or living in insecure
circumstances for longer periods and either
sleep rough, in squats or on friends’ floors
when not in the hostel system. The homeless
population is also very unevenly distributed
among PCT areas.
The Department of Health noted in 2010
“There is abundant evidence that people
who are sleeping, or have slept, rough and/
or are living in hostels and night shelters,
have significantly higher levels of premature
mortality and mental and physical ill health
than the general population.” (Healthcare for
single homeless people, Department of Health,
2010)
In addition, according to several sources, the
average age of death among people known to
be homeless is about 40 to 44. (Incidentally,
it is important not to cite these figures as life
expectancy rates. It simply means this was the
average age of death based on samples of
those who died while known to be homeless.)
Some of this can be attributed to the fact
that single homeless people have a high
incidence of physical health problems
compared to the general population. A
1994 study found that:
“Chronic chest or breathing problems and
frequent headaches were twice as high
among people in hostels and B&Bs and
three times as high among people sleeping
rough.
Wounds, skin ulcers and other skin
complaints were twice as high among day
centre users and three times as high among
soup run users.
Musculoskeletal problems were twice as
high among people sleeping rough.
Difficulty in seeing was experienced by
three times as many people sleeping rough
as the general population.
Mental health problems were eight times as
high among hostel and B&B residents and
eleven times as high among people sleeping
rough as the general population. One in
four single homeless people with mental
health problems had been in a psychiatric
hospital at some time in the past.
In comparison with the general population
heavy drinking or alcohol-related problems
were found to be less of a problem among
people in hostels and B&Bs than among
those sleeping rough.”
(Study by Wendy Bines of the Centre for
Housing Policy reported in Findings: housing
research 128, Joseph Rowntree Foundation,
1994)
Homeless Link’s Survey of needs and
provisions 2010 revealed that more than half
of homelessness projects across England see
clients who experience some sort of disability.
Disability can cover a range of conditions
including:
Learning difficulties
Mental health problems
Mobility
Sensory impairment
Developmental disability.
It is likely that some homeless clients have
an undiagnosed or unregistered disability.
Learning difficulties are particularly underreported and not always formally recognised
by professionals or included in commonly used
assessment tools.
4
6. Background
Aim of the guide
the community or in any other setting. The
guide is intended to support practitioners
and staff working in hostels to develop their
awareness and understanding of the end
of life care pathway and how it relates to
people in the hostel setting who have lifelimiting conditions. Of course, hostel staff
are not usually health care providers. Few
hostel staff possess specialist palliative care
skills while some hostels will not be able to
manage people with physical conditions or
those approaching end of life. So this guide
also offers signposting to more appropriate
resources.
Photo courtesy of St Mungo’s homeless charity
The aim of this publication is to provide a
practical guide which supports hostel staff
to engage with key professionals in ensuring
that those who may be in the last months
of their life receive high quality end of life
care. The guide may also be useful to health
professionals who work or link with hostels
in clarifying what measures need to be taken
to ensure that people can access appropriate
care.
Individuals approaching the end of their life
need high quality, accessible care if they are
to make genuine choices about how they
are cared for and where they wish to die.
Competent and compassionate care is also
critical to giving people the opportunity to
have a dignified death and offering families,
staff and other residents bereavement support
following a death.
This care should be of the same high quality
regardless of diagnosis and of whether the
care is carried out at home, in hospital, in
5
The guide has been developed by the National
End of Life Care Programme in conjunction
with a range of organisations working with
homeless people, as part of its route to success
series. It is intended to be a practical tool
offering advice on what staff can do as well
how and when to access specialist help.
7. Key considerations for delivery of end of life care
•
•
•
•
•
•
•
•
•
Care is client-centred and integrated
Treat individuals with dignity and respect
Identify and respect people’s preferences
Provide care after death
Do other professionals fully understand the
role of hostel staff?
Misconceptions about roles can lead to
mistaken assumptions. What can be done
to assist understanding?
The existing environment may not
encourage privacy or be suitable for
care and it may not be practicable to
consider rebuilding or remodelling hostel
environments. What other measures could
be taken?
Access to services may be problematic
because of other professionals’
misconceptions about an individual’s
background – for instance, homeless people
are often stigmatised as non-compliant and
unreliable. How can this be overcome?
The homeless population often decline to
engage with health services. What would
encourage them to engage?
Access to placement at end of life for
people with substance misuse problems
can be difficult because many care facilities
do not accept people with drug or alcohol
issues. Staff need to be aware of those
providers who do accept and provide for
this
Some individuals give very low priority
to their health needs. How will this be
managed within your service?
Some outreach services can have
bureaucratic barriers. How can these best
be overcome?
Many hostels tend not to retain residents
for a long time but help them move to
supported or independent living. With
collaborative working and planning this
should also be possible for those with end
of life care needs
• Many residents have very complex needs
including a high incidence of learning
difficulties, mental health problems and
dependency issues. As a result hostels may
not offer the best environment for end of
life care
• In future, health care will be commissioned
by localised GP consortia. It will be
important for hostel staff to be aware
who their local commissioners are and
to be involved in helping to identify their
residents’ health and social care needs
• Residents are often reluctant to plan ahead
but will inevitably see that other people in
the same situation have poor outcomes. An
open discussion about people’s expectations
can alleviate some of these concerns.
6
8. When to start thinking about end of life care
It is difficult to predict when people are
approaching the last 6 to 12 months of their
life but there are some ways hostel staff can
work with colleagues in health to improve
recognition and consider the important issues
that should be addressed at this time.
Providing effective, high-quality care for
someone during the end of their life is
challenging. Without support and information,
staff and carers can find the experience
overwhelming.
Identifying end of life care needs at an early
stage is beneficial and can allow more time
to plan appropriate support needs effectively
with and for someone. It may be that on
initial referral no specific action is taken, but
a resident’s future support needs and wishes
may be identified and their illness progression
can be monitored and reviewed when
appropriate.
This resource pack is intended to help you deal
with the challenges of supporting someone
who is dying and identify how and when you
need to access specialist support from health
professionals and other organisations.
It may be helpful to consider the
following when referring a resident to the
palliative care services or end of life care
services:
Where an actual prognosis is known:
• Who is the source of the prognosis (eg,
consultant, GP, clinical nurse specialist,
regional healthcare co-ordinator)?
• Is the resident aware of their prognosis?
• Is their prognosis months, weeks, days or
imminent?
• What are the main reasons for referral (eg,
physical, psychological, social, spiritual)?
• Is the resident aware you are making a
referral to the palliative care service?
7
Photo courtesy of St Mungo’s homeless charity
Where a prognosis is not known but there
are concerns that someone may be at end
of life:
• What is the primary/secondary diagnosis?
• Who is the source of the diagnoses (eg,
consultant, GP)?
• What are the main concerns for the
resident?
• Is the resident aware of your concerns?
• Who else is aware of these concerns?
• Have these concerns been discussed with
any of the following: consultant, GP, clinical
nurse specialist/district nurse, regional
healthcare co-ordinator?
(Checklist devised by St Mungo’s)
9. End of life care pathway
The guide follows the six steps of the end of
life care pathway, beginning with initiating
discussions as end of life approaches and
concluding with care after death.
Each section outlines the relevant step of
the pathway, questions to ask about the
individual’s care and the practitioner’s role in
that care. (Reference can also be made to the
relevant quality markers for end of life care.
See Appendix 1 for full list.) We also include
case studies highlighting best practice.
Step 1
Step 1
Discussions
Discussions
as the end
as the
of life end
of life
approaches
approaches
Open, honest
communication
Identifying
triggers for
discussion.
Step 2
Step 2
Step 3
Step 3
The guide will reflect the need to work
with other professionals in health and
social care and assist hostel staff to:
• Identify when someone is approaching the
end of life phase
• Assess needs and develop a care plan
• Review care planning
• Help to review practice
• Support communication and team working
• Understand that staff and fellow residents
may be affected by the death of a client
and identify some measures to support
them and provide information.
Step 5
Step 5
Step 6
Step 6
Delivery of
Delivery of
high quality
high quality
services in
services in
different
different
settings
settings
Care in the
Caredays
last in the
last days
of life
of life
Care after
Care after
death
death
High quality
care provisions
in all settings
Acute
hospitals,
community,
care homes,
extra care
housing
hospices,
community
hospitals,
prisons, secure
hospitals and
hostels
Ambulance
services.
Identification
of the dying
phase
Review of
needs and
preferences
for place of
death
Support for
both patient
and carer
Recognition
of wishes
regarding
resuscitation
and organ
donation.
Recognition that
end of life care
does not stop
at the point of
death
Timely
verification and
certification of
death or referral
to coroner
Care and support
of carer and
family, including
emotional
and practical
bereavement
support.
Step 4
Step 4
Assessment,
Assessment,
care planning
care planning
and review
and review
Co-ordination
Co-ordination
of care
of care
Agreed care
plan and
regular review
of needs and
preferences
Assessing
needs of
carers.
Strategic coordination
Co-ordination
of individual
patient care
Rapid
response
services.
Social
Social care care
Social care
Spiritual care services
Spiritual care services
Support for carers and families
Support for carers and families
Information for patients and carers
Information for patients and carers
8
10. Step 1
Discussions as the end of life approaches
“It can be very difficult to predict when a resident is going to die. We tend to try
to find informal and supportive ways to broach the subject with each and every
one of them if possible. Sometimes this is about picking up on a comment or
remark made about their mortality, and using this as an entry point to further
discussion.” Hostel staff member
Identifying when people are approaching
the end of their life can be complex. Many
hostel residents may have conditions like liver
damage and respiratory problems where the
stages of deterioration can be unpredictable.
9
A key challenge is knowing how and when
to begin a discussion with individuals about
their wishes as they near the end of life and
whether they should be referred to other
services.
11. Discussions as the end of life approaches
Ask yourself
How do you identify residents who are
approaching the end of life?
Are you aware of any triggers which
indicate it is an appropriate time for
discussion?
Are you certain you know whether a
client does or does not wish to have a
conversation about their future care?
What is your referral process to other
services? Do you have a robust referral
pathway?
Your role
Recognise when an individual’s signs and
symptoms have increased or condition has
deteriorated
Ask yourself the question “Would I be
surprised if this person were to die at some
stage in the near future?”
Identify, with the help of health
professionals, those who need to receive
end of life supportive care
Consider carefully whether the individual
wishes to have open discussions about
prognosis and possible future care options
Identify whether it is appropriate to open
a supportive discussion with the resident
about their wishes for end of life care and
the best time or circumstances to do that.
Consider accessible information, particularly
for those for whom reading may be an
issue due to learning difficulties, lack of
education and/or if English is not their first
language
Provide any relevant information required,
whether that is about the individual’s
condition, financial support, access to
specialist palliative care services or anything
else.
Top tips
Death and dying should not be hidden
from residents, relatives and carers.
Building a trusting relationship will help
facilitate conversations that may include
end of life care. Consider who else
needs to be involved
Consider how to integrate
conversations into existing activities and
assessments such as substance use or
general key worker discussions
Recognise that greater attention and
support may be required for those
residents who struggle to communicate
their needs because of learning
difficulties, dementia or other health
problems
As a caregiver it is important you
recognise how your own attitude to
death and dying may influence the
care you provide and your ability to talk
openly about these issues
Try to provide private spaces in which
to break bad news or initiate end of life
care discussions.
10
12. Discussions as the end of life approaches
Case study
Raising the subject of someone’s
approaching death is one of the most
difficult conversations you can have with
a resident, says Dave Millburn, but he
has become accustomed to it over the 12
years he has managed 32 Bentinck Road in
Nottingham.
The home offers long-term care and
support for 21 residents, all of whom are
50 or over. Most were previously homeless
and although some improve and move out,
many others stay there till they die.
Dave and his fellow members of staff will
not usually be the ones to break the bad
news in the first place. But immediately
afterwards they will be deeply involved
in trying to help their clients focus on
how and where they wish to spend their
remaining time.
“It’s a matter of trying to have an honest
and realistic dialogue at that stage,” he
says. “I often encounter a degree of shock
from the individual that at the age of, say,
50, they are dying. They say: ’How did I get
here?’”
One of the keys, he says, is trying to
connect with the individual and their
particular tragedy. “They didn’t plan for
this way of life. It’s invariably happened
because of a series of misfortunes and you
need to be able to understand this.”
It is vital to get the timing and the tone
of this conversation right, he says. Often
there will be a chance after someone has
been told they have a terminal condition to
sit down over a drink and ask them where
they want to go from here. “Most people
seem to want to engage with that.”
11
Dave says he tries to talk about practical
matters as well as people’s priorities.
He also looks for catalysts such as, for
instance, someone choosing a ‘weepie’
DVD that may offer an opening to talk
about what’s going on in their lives.
He notices a mood of “quiet observance”
when someone is dying within the
home. “The whole home feels it when
that happens. It’s just in the air. And it’s
something that has to be respected.”
13. Step 2
Assessment, care planning and review
“People here find it hard to go to people to talk about their health. We need
coaxing … because we’re all messed up.” Cedars Road client
An early assessment of a resident’s needs and
wishes as they approach the end of life is vital
to establish their preferences and choices,
as well as identifying any areas of unmet
need. It is important to explore the physical,
psychological, social, spiritual, cultural and,
where appropriate, environmental needs and
wishes of each resident.
12
14. Assessment, care planning and review
Ask yourself
Does your care plan assessment take into
account all aspects of end of life care
(social, emotional and spiritual) as well as
physical?
Who else needs to be involved in this
process?
Do you feel sufficiently confident and skilled
in supporting residents to identify their
wishes and preferences about their future
care? Might additional training and support
be valuable?
Your role
Consider how you can work with others
to ensure that a holistic assessment can
take place about the individual’s end of life
needs and preferences
Assess and respond sensitively to the social,
psychological and spiritual needs and
wishes of a resident as well as their physical
care needs
If necessary, support an assessment of the
individual’s ability to make decisions about
their care (guidance provided in the Mental
Capacity Act 2005 code of practice, see
Appendix 2)
Work with others to identify, record and
respond to an individual’s personal wishes
and preferences about their future care
(advance care planning), implement regular
reviews and verify this with their local GP if
necessary
Provide clients with a method of recording
their wishes and preferences. If they choose
to include an advance decision to refuse
treatment appropriate advice should be
sought
Communicate information about personal
wishes and preferences (with permission) to
relevant people such as the GP and out-ofhours service.
13
Top tips
If a resident makes an advance decision
to refuse life-sustaining treatment
it must be in writing, signed by that
person (or representative) and witnessed
Holding an open meeting with residents
can be a way of raising awareness about
the possibility of expressing personal
wishes and preferences
Care planning discussions may need to
take place in stages to avoid tiring the
person. This may also be the case should
the resident have learning difficulties or
mental health issues
Complete a key contact sheet as per
hostel paperwork already in situ (or
consider devising one) and keep in a
readily accessible place
Encourage hostel staff to have an input
into care planning discussions when
appropriate.
15. Assessment, care planning and review
Case study
The homeless charity St Mungo’s and
Marie Curie Cancer Care have set up the
first palliative care service in the UK for
homeless people with terminal illnesses.
One of the chief aims is to enable clients to
make informed decisions about how they
would like to be cared for until they die.
Other aims of the service, which has
been operating since September 2009,
are:
• Respect for an individual’s cultural
attitudes about death, enabling them to
die with dignity
• Helping to deal with the psychological
and emotional aspects of coming to the
end of life
• Death occurring in the environment
chosen by the service user.
The service’s first step is an initial
assessment to see if a client meets the end
of life care criteria. The question “Would
I be surprised if this person was to die
within the next 6 to 12 months?” can
help staff identify early on if someone is
approaching the end of their life.
Once a client is seen to meet the criteria,
the service can then begin to explore their
understanding of what is happening and
their preferences and wishes. Clients need
to be told about appropriate support,
particularly specialist palliative care support
for dealing with the different aspects of
end of life care. But above all they should
remain in control of the choices around
end of life issues, however difficult that is
for staff.
The service is led by Palliative Care Coordinator Peter Kennedy, whose role is to
co-ordinate care between the resident,
significant others, community palliative
care services, medical consultants and St
Mungo’s staff. He also provides training
and support to hostel staff.
Many residents’ illness trajectories are
difficult to predict, he says. “Over 90%
of deaths in St Mungo’s projects are
perceived as ‘sudden’, although not
necessarily unexpected. It is also difficult
to assess the severity of people’s illness,
particularly those with advanced liver
disease. The average age of death among
residents in our projects is 46.
“Another challenge is that many clients
approaching the end of their life have
mental health and substance use
problems. Working in partnership with
statutory and non-statutory agencies is
paramount in meeting the multiple needs
of those clients.”
14
16. Step 3
Co-ordination of care
“One challenge is that many clients approaching the end of their life have
mental health and substance use problems. Working in partnership with
statutory and non-statutory agencies is paramount in meeting the multiple
needs of those clients.” Peter Kennedy, St Mungo’s
Once a care plan has been agreed it is
important that all the services the resident
needs are effectively co-ordinated. Individuals
should be asked for permission to share
information with other services.
15
This is also an opportunity to establish contact
details for anyone they would like to be
notified if there is a change in circumstances
– and can in certain cases be used to help reestablish links with families.
17. Co-ordination of care
Ask yourself
Is there a communication system in place to
keep all members of the hostel team as well
as others such as friends and health and
social care professionals fully informed of
the end of life care plan?
Has a key worker been identified within the
hostel who can develop a strong working
relationship with those key professionals
who may be needed in order to meet the
end of life care plan?
Are systems in place for services to respond
rapidly and appropriately, (out-of-hours as
well as during working hours) to changes
in circumstances as end of life approaches?
For example, is there ready access to
medication and special equipment?
Your role
Top tips
Find out which pharmacies your local
hospice uses. These are more likely to
offer out-of-hours delivery of drugs
Building strong relationships with other
services – for instance, GPs, palliative
care teams and social care – can help
you provide residents with good end of
life care
Remember: good communication
systems need to work in both directions
and meet the needs of those at the
centre of the care
Phone calls between a dying person
and health professionals or relatives
can maintain contact and resolve some
issues without the need for a visit.
Ensure local healthcare professionals are
aware of those approaching the end of life.
Some GP practices may be implementing an
end of life care register. Is the hostel linked
to this multidisciplinary team mechanism?
Make sure good communication systems
are in place with all relevant services
Ensure you know who your key contacts
are across the provider services, voluntary
bodies and social care sectors
Try to ensure that individuals have the
benefits they are entitled to. These can
be claimed for under special rules when
someone is approaching the end of life. A
doctor has to sign a special form to initiate
this process (DS1500)
Inform out-of-hours services of anticipated
care needs
Inform ambulance services of anticipated
care needs.
Photo courtesy of St Mungo’s homeless charity
16
18. Co-ordination of care
Case study
Watching hostel clients in their final stages
can often be a distressing and painful
experience, says Danielle, a project worker
at St Mungo’s hostel in St Pancras, London.
Danielle works at a ‘continued use’ hostel,
which means all 21 clients at the home
are allowed to continue with their drink
and drug habits while staying there. The
principal aim is to provide them with a safe
space while offering support to help them
move forward in their lives.
Danielle works on a weekly or fortnightly
basis with four of these clients, agreeing
objectives – such as getting into meaningful
activities, training or employment, moving
into permanent accommodation or
accessing health services – and then doing
what she can to support them to achieve
their chosen goals.
Given their substance abuse, health
problems, such as liver damage in
particular, are never far away and while
some do manage to move on to lead more
independent lives, others do not. Sadly, last
year two of the hostel’s clients died – one
at the hostel and one in hospital.
In each case the end came quite suddenly
– although staff had seen signs they
were declining for some time before. The
problem, says Danielle, is that most of her
clients, being at the pre-contemplative
stage, tend to deny what is happening to
them so rarely have much time to prepare
for their death.
One client was drinking heavily and
vomiting and then bleeding. But every
time he was admitted to hospital he was
patched up and then discharged without
any specific advice or support. “The only
17
thing the doctors said was that of course
he was going to be like this because he
was drinking so heavily.” The man was
eventually referred to the St Mungo’s
palliative care service while his health
continued to deteriorate.
“We always try to make clear their
choices,” says Danielle, “but sometimes
they decide they don’t want to stop
drinking. But it’s difficult to see the decline
and not to be able to do anything about
it.”
Staff do also see signs of improvement
among other clients and many move on
to more independent lives, which makes
the job worthwhile. “They often say they
dislike the place when they first arrive,
but then after they leave you find them
coming back to chat with staff and/or
residents while they discuss where they’re
at, so that’s when you know you’ve done a
good job.”
19. Step 4
Delivery of high quality services in different settings
“We always try to make clear the choices they have but sometimes they decide
they don’t want to stop drinking. But it’s difficult to see the decline and not to
be able to do anything about it.” Danielle, St Mungo’s
In the last year of life, residents and their
families may need access to a complex
combination of services across a number of
different settings. They should be able to
expect the same high level of care regardless
of where they are being looked after. For
some - such as those who are frequently in
hospital - it may be useful to have a more
proactive approach.
18
20. Delivery of high quality services in different settings
Ask yourself
Has a policy for the management of end
of life care been developed within your
organisation? For instance, is there a
policy for what to do if a crisis occurs at a
weekend or in the middle of the night?
Can all staff access any internal or external
training and support programme for end of
life care?
Does the environment within the hostel
offer privacy, dignity and respect for
individuals and their families as the end of
life approaches?
What process is in place for referral to other
care settings if your hostel does not provide
end of life care?
What systems are in place to monitor and
evaluate the quality and delivery of end of
life care?
Can you ensure that any transition from the
hostel to a hospital is well co-ordinated and
minimises any distress for your client?
Your role
Establish or be aware of the operational
policy for implementing end of life care in
your hostel
Ensure you have awareness and
understanding of end of life care core
principles and values
Promote or participate in the different
aspects of end of life care training which
may be available to you. There is no set
format for the delivery of training
Where possible, access training around
communication skills, assessment and care
planning, advance care planning, symptom
management and comfort and well-being
Give consideration to the environment
in which end of life care and support is
delivered. For example, is there access to a
quiet room or other facilities for relatives?
Use the experiences of relatives, staff or
advocates to help provide constructive
feedback to support continuous practice
improvement
Work with key professionals to find an
appropriate place of care when it is no
longer possible to provide care in the hostel.
19
Top tips
Don’t forget the role that other
residents, particularly those who have
developed a close relationship with the
person who is dying, may be able to
play in the planning and delivery of care
Staff training needs should include not
only the physical aspects of care but also
psychological and spiritual care
Try to help the resident maintain the
maximum level of independence, choice
and control for as long as possible
It might be worth discussing with
community matrons and community
urgent care providers when it would be
appropriate to contact them. Ask for
information and contact numbers
Consider adapting end of life care tools
- that is, guidance and support to help
staff caring for people at the end of life
- for use in the hostel environment.
21. Delivery of high quality services in different settings
Case study
The Homeless Intermediate Care Pilot
Project has provided care and support to
a group of clients with life-threatening
conditions at the St Mungo’s Cedars Road
hostel in Clapham, London over the last
18 months, reducing deaths and cutting
hospital admissions.
The main purpose of the project, which
began in January 2009, was to reduce
mortality and morbidity while also cutting
secondary care usage. In 2008 there were
7 deaths with an average age among those
who died of 38. Since then there have been
only 3 deaths.
The project team consists of a band 7
nurse, a health worker and a sessional
GP, and offers intensive support to up to
10 clients at a time for 6 to 12 weeks. Its
main activities include outreach, clinical
interventions, liaison and referrals, screening
and advocacy.
Nearly 4 out of 5 clients have undergone
pre-detoxification. In addition, 90%
of women received cervical and sexual
health screening, 96% of all clients had
a comprehensive health assessment and
87% had a full blood screen.
Key workers say they now feel better
equipped to deal with health emergencies
and have more knowledge about the
conditions suffered by their most unwell
clients.
The plan is to move towards residents
dying in the place of their choice, usually
the hostel, says project lead Samantha
Dorney-Smith. However, because deaths
are often sudden, this has not always been
possible. “We do attempt to ensure death
is as dignified as possible and to re-engage
people with their families at the end.”
The level of illness and disease among
the 34 clients cared for over the first pilot
year was extremely high. 24% had had a
diagnosis of HIV, 34% had past hepatitis B
and 84% active or past hepatitis C. 83%
had been intravenous drug users, 74%
alcohol dependent and 88% had had
mental health problems. Many suffered
from serious conditions such as end stage
liver failure, acute syphilis and pulmonary
TB.
During that year the project has cut
London Ambulance Service calls by 67%,
hospital admissions by 77% and A&E
admissions by 52%. Repeat attendances
are also down. The length of admission has
increased slightly, reflecting a reduction in
inappropriate and self-discharges.
20
22. Step 5
Care in the last days of life
“In principle you do want to be able to support someone around the point of
death at home because the patient would want it rather than in hospital. The flip
side of that is that death in the hostel can be very upsetting both for other clients
and also for staff.” Samantha Dorney-Smith, Three Boroughs Homeless Team
A point comes when an individual enters the
dying phase. For some this may appear to
happen suddenly and without warning but
for many others it can be a gradual process.
It is vital that staff are able to recognise when
21
a person is dying and take the appropriate
action. How someone dies remains a lasting
memory for the individual’s relatives, friends
and the care staff involved.
23. Care in the last days of life
Ask yourself
Are you aware of the changes which may
occur in an individual’s condition during the
dying phase?
Are systems in place for involving friends,
fellow residents and, where appropriate,
families in aspects of the care-giving or in
discussions as death approaches?
Has the resident indicated any specific
wishes or preferences for this time?
Has the Liverpool Care Pathway (an end of
life care tool for those in their last days or
hours) or other equivalent pathway been
implemented?
Have you responded to any particular
spiritual or cultural needs that have been
recorded as part of the end of life planning?
Your role
Top tips
Discuss with medical staff the support
which would be required for the
resident to remain in the hostel
Where possible, plan to have someone
- a member of staff, health professional
or volunteer - available to sit with the
dying person. This will provide them
with comfort and reassurance
Consider ways to support any
residents, friends or relatives that the
individual wants to be present by
providing, where possible, transport,
accommodation, meals and emotional
support
Support people with the same respect
you would want for yourself or a
member of your own family.
Be aware of the processes which occur
during the last days of life and be alert
to the possibility that on occasions an
individual’s condition may improve
Have open discussions with relatives, friends
and other members of staff to ensure you
all know what to expect during the last days
of life, and offer support where needed
Where possible adhere to an individual’s
stated wishes and preferences
If someone lacks mental capacity, try to
identify what they would take into account
if they could make their own decisions
Where possible have anticipatory
prescribing systems in place or a system for
rapid access to necessary medication
Anticipate and be prepared for any specific
religious, spiritual or cultural requests a
resident may make.
Photo courtesy of St Mungo’s homeless charity
22
24. Care in the last days of life
Case Study
Mary was a 44-year-old woman with
learning difficulties living at a local
authority hostel in Leicester when she
attended the Homeless Healthcare’s
weekly GP service to have a cervical smear.
The results were severely abnormal and
an advanced cancer of the cervix was
diagnosed, which required treatment with
chemotherapy and radiotherapy.
Mary had no family contact but with her
consent and with her input, her needs
were met by co-ordinating all aspects of
her care between the local authority, the
local hospice and Homeless Healthcare.
A member from the Homeless Healthcare
team attended every hospital clinic
appointment and all appointments for
treatment with her to ensure she wasn’t
alone and unsupported.
During treatment Mary was often unable
to completely self manage and the local
authority facilitated a transfer from the
self-catering women’s hostel where she
was staying to a self-contained ensuite flat
within the multi-agency Dawn Centre, a
44-bed hostel and YMCA drop-in centre
which also accommodates the Homeless
Healthcare health suite.
During this time her application for a
bungalow reached the top of the housing
list but rather than moving her out quickly
as was usual practice, the local authority
liaised closely with Mary and partner
agencies and ensured her treatment was
complete and that she would be able
to manage before she moved on. Social
services arranged for a package of care
to be delivered daily and members of all
four agencies (that is, GP service, hospice,
local authority, social services) worked
23
collaboratively to ensure that a high
standard of care was consistently delivered
and all her needs were holistically met.
When her condition deteriorated and
she needed admission to the oncology
unit, a multi-agency case conference
was arranged with both Mary and the
above agencies present. She chose not to
return to her bungalow with an increased
package of care or to the local hospice but
instead chose to move to a nursing home.
Following an accompanied visit by a
member of the Healthcare Inclusion team
she selected a bed in a local nursing home
experienced in delivering palliative care
and where she eventually died. On one
of the team’s routine visits she said how
happy she was there.
25. Step 6
Care after death
“Over 90% of deaths in St Mungo’s projects are perceived as ‘sudden’,
although not necessarily unexpected. The average age of death among
residents in our projects is 46.” Peter Kennedy, St Mungo’s
Good end of life care doesn’t stop at the point
of death. When someone dies all staff need to
follow good practice for the care and viewing
of the body as well as being responsive to
family wishes. The support provided to staff,
friends and relatives will help them cope with
their loss and is essential to achieving a ‘good
death’.
24
26. Care after death
Ask yourself
Do mechanisms exist to support non-family
members such as staff, residents and friends
who may also be affected by a death?
Is there a clear plan to communicate the
death to any family members who have not
been involved until now?
Are systems in place for advising on or
offering bereavement support to staff,
friends and relatives?
Your role
Respect individuals’ faiths and beliefs and
take steps to meet their requirements
Be aware of verification and certification of
death policies
Provide appropriate information to relatives
and carers about what to do after a death
Offer information about bereavement
support services if required
Provide a comfortable environment in which
staff and, where appropriate, residents can
discuss or share their feelings
Provide staff, residents and relatives with
the opportunity for remembering and
celebrating an individual’s life in their own
way.
25
Top tips
Residents can be remembered through
photos and collages. Sometimes it is
really helpful for families to see the
photographs around the hostel after
someone has died – especially if they
haven’t been in touch with them
Recognise that a resident’s death may
be more significant to some than to
others and they may require additional
support – as may hostel staff
Train volunteers to support dying
people and their families and friends
and offer support to bereaved people
Hostel staff should be prepared for
relatives expressing anger if they have
not been contacted. They may also be
deeply regretful if they were estranged
from the individual before their death
Use review and feedback to support
continuing improvement.
27. Care after death
Case study
St Mungo’s aims to support those affected
by a resident’s death in a range of ways,
says the charity’s Palliative Care Coordinator, Peter Kennedy.
Deaths in projects are not uncommon and
are often sudden. As a result, a death can
leave residents and staff deeply upset and
sometimes traumatised.
There are many ways in which St Mungo’s
projects commemorate someone’s death.
Many set up a book of condolence. Some
arrange for a tree to be planted or for a
bench to be erected. Others hold annual
remembrance services.
What staff do in the immediate aftermath of
a death is vital, says Peter. This includes how
they inform clients, especially significant
others, of a death, as well as trying to
include them in funerals or remembrance
services. “This is really important for
lessening the impact and allowing clients to
express themselves. And it brings everyone
together.”
It is important to have systems in place
within the organisation that help to open
up dialogue with staff on how they can
support each other and then support their
clients.
Supporting relatives can also be
challenging. In many cases the individual
will have had little or no contact with
family members, so the first news they
may get after a long interval is that their
relative is dead. This can be stressful
for staff, particularly if they are caught
between carrying out the wishes of a
client and trying to deal openly and fairly
with relatives following a death.
Peter admits there is still some way to
go. “But more one-to-one, team support
and bereavement training is being made
available for staff and they now feel
much more assured that they have done
everything they could.”
It is also a time of high risk. Clients
tend not to have strong social support
networks, particularly outside the project.
The death of someone close can send
them into a downward spiral which has a
knock-on effect on other residents. Peter
suggests it may be sensible to start making
bereavement risk assessments in advance.
The effects of a death can also create high
levels of stress for staff who must try and
continue with ‘business as usual’ despite
their clients’ distress, which they may be
sharing.
26
28. Next steps
Identify how well your organisation is
prepared for managing the needs of
someone reaching the end of their life
The ideal time to talk to people about
end of life issues is when they are still
well. It may be helpful to sign up to an
organisation like the Dying Matters coalition
to get access to free leaflets and guidance
that can help open up discussions earlier
What policies and referral pathways are in
place now and how can they be improved?
(see Appendix 3 for an example of a
palliative care pathway developed by St
Mungo’s)
Share this information with all staff who
may be involved in the delivery of end of life
care
Complete the key contacts sheet and keep
in a visible place. This will allow you to have
available local information about relevant
services including bereavement services
Consider if it would be useful for a
dedicated person to do a course in
bereavement counselling
Look after yourself and each other: build in
time to talk about difficult situations
Find out if there is any available training in
your area
Check the available resources which are on
the National End of Life Care Programme
website
Check National End of Life Care Programme
support sheets relevant to this publication.
27
29. Next steps
Are you prepared as an organisation?
Case study
Joanne is 30 years old. She began drinking
heavily at age 14 and for many years
has been using substances such as crack
cocaine and heroin. She was diagnosed
with advanced liver disease 12 months
ago. In a recent hospital admission the
medical team told her that if she did not
stop drinking her life expectancy would be
less than six months.
Joanne is currently awaiting the outcome
of an application for funding for a detox/
rehab programme. Her engagement
with substance use agencies is erratic
and her motivation poor. She still has
periods of feeling unwell with admissions
to hospital. But she continues to receive
psychological and emotional support
from staff and has been introduced to the
community specialist palliative care team.
She is currently being considered for
funding for her third detox/rehab
programme in two years due to the
seriousness of her condition. In her
previous two programmes she completed
detox but did not reach the rehab stage.
She is aware of how unwell she is and
continues to live with the belief that she
will die within months if she does not get
into a detox/rehab programme.
Many staff at the hostel where Joanne lives
were insistent she had to stop drinking
immediately to improve her chances of
living longer. But it is important to allow
clients to remain in control of the choices
they face when dealing with end of life
issues, however difficult staff find them.
Photo courtesy of St Mungo’s homeless charity
In Joanne’s case this meant accepting the
possibility that, for whatever reasons, she
may not be able to undertake or complete
a detox/rehab programme, knowing that it
will shorten her life. It was also important
to let her know that staff would back
her request for another chance at detox/
rehab and that whatever the outcome they
would provide support. This allowed her
to retain control of her life but not feel
abandoned, regardless of the choices she
made.
28
30. Useful resources
For further details on the case studies in this
document go to www.endoflifecareforadults.
nhs.uk/case-studies
End of life care strategy: promoting high
quality care for all adults at the end of life,
Department of Health, 2008
People not paupers: who cares when someone
dies homeless?, UNLEASH (Church Action on
Homelessness in London), 1998
Healthcare for single homeless people,
Department of Health, March 2010
Dying for a home, Dr Christine Hugh-Jones,
The Willow Walker (magazine working with
homeless people in Cambridge, now known as
FLACK), Autumn 2009
Personal health budgets: understanding the
implications for staff, Department of Health,
2009
NHS Choices (patient information)
End of life care in advanced kidney disease:
a framework for implementation, National
End of Life Care Programme/NHS Kidney
Care, 2009 (See National End of Life Care
Programme website for further examples of
condition specific publications)
Common core competences and principles for
health and social care workers working with
adults at the end of life, National End of Life
Care Programme/Department of Health/Skills
for Care/Skills for Health, 2009
Carers at the heart of 21st century families and
communities: a caring system on your side, a
life of your own, Department of Health, 2008
29
Preferred priorities for care (PPC), National End
of Life Care Programme, 2007
Advance care planning: a guide for health
and social care staff, National End of Life Care
Programme/University of Nottingham, 2008
Advance decisions to refuse treatment: a
guide for health and social care professionals,
National End of Life Care Programme/National
Council for Palliative Care, 2008
Mental Capacity Act 2005 code of practice,
Department for Constitutional Affairs, 2007
(See also Appendix 2: Support sheet Mental
Capacity Act)
Best interests at the end of life: practical
guidance for best interests decision making
and care planning at end of life, Hutchinson/
Foster (Central Lancashire PCT/East Lancashire
PCT), 2008
Planning for your future care: a guide, National
End of Life Care Programme/National Council
for Palliative Care/University of Nottingham,
2009
Making a will (Directgov guidance on wills
including links to Citizens Advice Bureau guide
to making a will and Age Concern fact sheet)
Our health, our care, our say: a new
direction for community services, Department
of Health, 2006
Living and dying with dignity: the best practice
guide to end-of-life care for people with a
learning disability, Mencap, 2008
End of life care strategy: quality markers
and measures for end of life care, Department
of Health, 2009
31. Useful resources
Transforming community services: ambition,
action, achievement transforming end of life care,
Department of Health, 2009
Macmillan out-of-hours toolkit learn zone. See www.
macmillan.org.uk/learnzone
Gold Standards Framework
The Liverpool Care Pathway for the Dying Patient
Can you see me? (DVD), The National Council for
Palliative Care, 2010
Useful websites and organisations that have
contributed to this publication:
Crisis www.crisis.org.uk
Dying Matters coalition www.dyingmatters.org
Homeless Link www.homeless.org.uk
Marie Curie Cancer Care www.mariecurie.org.uk
National Council for Palliative Care www.ncpc.org.uk
National End of Life Care Programme www.
endoflifecareforadults.nhs.uk
National Veterans Foundation www.nvf.org
Salvation Army www.salvationarmy.org.uk
Shelter www.shelter.org.uk
St Mungo’s www.mungos.org
Thames Reach www.thamesreach.org.uk
30
32. Appendix 1
Quality markers for end of life care
(End of life care strategy: quality markers
and measures for end of life care, Department
of Health, 2009)
1. Have an action plan for the delivery
of high quality end of life care, which
encompasses clients with all diagnoses,
and is reviewed for impact and progress.
2. Institute effective mechanisms to identify
those who are approaching the end of life.
3. Ensure that people approaching the end of
life are offered a care plan.
4. Ensure that individuals’ preferences and
choices, when they wish to express them,
are documented and communicated to
appropriate professionals.
5. Ensure that the needs of carers are
appropriately assessed and recorded
through a carer’s assessment.
6. Have mechanisms in place to ensure that
care for individuals is co-ordinated across
organisational boundaries 24/7.
7. Have essential services available and
accessible 24/7 to all those approaching
the end of life who need them.
8. Be aware of end of life care training
opportunities and enable relevant
workers to access or attend appropriate
programmes dependent on their needs.
9. Adopt a standardised approach (the
Liverpool Care Pathway or equivalent) to
care for people in the last days of life.
10. Monitor the quality and outputs of
end of life care and submit relevant
information for local and national audits.
31
33. Appendix 2
Support sheet Mental Capacity Act How should people be helped to
make their own decisions?
(Compiled from the Mental Capacity Act 2005
code of practice by Julie Foster, End of Life
Care Lead, Cumbria and Lancashire End of Life
Care Network)
The Act is intended to be enabling and
supportive of people who lack capacity, not
restricting or controlling of their lives. It aims
to protect people who lack capacity to make
particular decisions, but also to maximise their
ability to make decisions, or to participate in
decision-making, as far as they are able to do
so.
The five statutory principles are:
1. A person must be assumed to have capacity
unless it is established that they lack
capacity.
2. A person is not to be treated as unable
to make a decision unless all practicable
steps to help him to do so have been taken
without success.
3. A person is not to be treated as unable to
make a decision merely because he makes
an unwise decision.
4. An act done, or decision made, under this
Act for or on behalf of a person who lacks
capacity must be done, or made, in his best
interests.
5. Before the act is done, or the decision is
made, regard must be had to whether
the purpose for which it is needed can
be as effectively achieved in a way that is
less restrictive of the person’s rights and
freedom of action.
To help someone make a decision for
themselves, check the following points:
Providing relevant information
Does the person have all the relevant
information they need to make a particular
decision?
If they have a choice, have they been given
information on all the alternatives?
Communicating in an appropriate way
Could information be explained or
presented in a way that is easier for the
person to understand (for example, by using
simple language or visual aids)?
Have different methods of communication
been explored if required, including nonverbal communication?
Could anyone else help with
communication (for example, a family
member, support worker, interpreter,
speech and language therapist or
advocate)?
32
34. Appendix 2
Assessing capacity
Anyone assessing someone’s capacity to
make a decision for themselves should use
the two-stage test of capacity.
Does the person have an impairment of
the mind or brain, or is there some sort of
disturbance affecting the way their mind or
brain works? (It doesn’t matter whether the
impairment or disturbance is temporary or
permanent.)
If so, does that impairment or disturbance
mean that the person is unable to make the
decision in question at the time it needs to
be made?
Assessing ability to make a decision
Does the person have a general
understanding of what decision they need
to make and why they need to make it?
Does the person have a general
understanding of the likely consequences of
making, or not making, this decision?
Is the person able to understand, retain, use
and weigh up the information relevant to
this decision?
Can the person communicate their decision
(by talking, using sign language or any
other means)? Would the services of a
professional (such as a speech and language
therapist) be helpful?
Assessing capacity to make more complex
or serious decisions
Is there a need for a more thorough
assessment (perhaps by involving a doctor
or other professional expert)?
33
35. Appendix 3
St Mungo’s palliative care service pathway
Receipt of referral to PCC
PCC contacts referrer for
more verbal information
Does the resident meet St
Mungo’s referral criteria for PC
services?
Identificatipn of key
care workers
No
Pass on to alternative more
appropriate services
No
Identify key concerns
Identify key professionals
Identify action points
Yes
PCC contacts referrer for
initial assessment
Yes
Does the resident wish to
engage with the PC services?
Attempt to engage
resident re identified
concerns/
medical consent
Contact and visit resident
Identify resident’s wishes
Assessment of care needs
Yes
Does the resident wish
to engage?
PCC undertakes review with key
caseworker(s) of available services to
support resident’s choice
Can the resident’s wishes be
supported practically?
No
Yes
Enable services to be put
into place
No
No
Consider alternative options
Yes
Implement care plan
Do the resident’s needs/
wishes change?
34