Coordinating care at the end of life

Photo: Sara Scarborough (Macmillan Clinical Nurse Specialist) and Joel McIlveen (Associate Nurse Specialist)

Under the direction of the Trust’s End of Life Care Steering Group which includes, governors, bereaved family members, community representatives and voluntary services, and members of the hospital team, the hospital has been implementing a number of actions to improve patient and family care at the end of life.

This has included moving to a seven day face-to-face palliative care nursing service and ensuring staff are supported to deliver the key principles of good end of life care.

The aim of our End of Life Care Strategy is to ensure consistency and excellence in delivering 24-hour care to people, and to their families, in the last 12 months of life while in hospital and we are also working with our community partners to ensure patients are able to be in their preferred place of care.

An important aspect of this work is sensitively identifying patients who may be moving into their last year of life and working with them and their family members to ensure their wishes and plans are recognised early and acted upon.

An essential aspect of ensuring patients’ wishes are addressed is, with the patient’s permission, sharing their wishes with their GP and their community services. Working together and in a collaborative manner means we can ensure that the personal wishes can be realised.

With this in mind, Chelsea and Westminster is using Coordinate My Care (CMC) which has been developed to give people with chronic health care conditions and/or life-limiting illnesses an opportunity to create a personalised care plan to express their wishes and preferences for how and where they are treated and cared for.

At the heart of CMC is a care plan that is developed with a patient, his/her family members and nurse and/or doctor in a sensitive and supportive manner when it is appropriate.

The care plan is uploaded to the CMC electronic system which is only accessible by trained professionals involved in the patient’s care.

These include GPs, out-of-hours services, hospitals, nursing and care homes, hospices and community nursing teams, ambulance control staff and NHS 111 operators.

By sharing this information in a safe and secure manner we are better able to support patients and their families with the care they want.

If you would like to know more about Coordinate My Care for yourself, a family member or someone you are looking after, please contact Sara Scarborough or Joel McIlveen from our Palliative Care Team on 020 3315 8499 or online at www.coordinatemycare.co.uk.