There are many health and social care professionals who may work with you if you are receiving palliative care:
Specialist palliative care team
There are two community teams in Leeds – the St. Gemma’s team covers the eastern half of the city and the Wheatfields team covers the western half. The teams consist of Community Clinical Nurse Specialists (CNSs), a Consultant in Palliative Medicine and other doctors. The CNSs are nurses who have often worked in the hospice or as District Nurses previously and have then gained further training and experience in Palliative Care. Clinical Nurse Specialists are available to discuss issues which may be having an impact on your life whether physical, emotional, spiritual or social. The CNSs have a good knowledge of what can often help, including medication to improve symptoms such as pain, sickness or breathlessness. They have time to discuss thoughts and feelings you may wish to share and give information which can often help you make choices. The team is here to support you and your family.
The CNSs work closely with the Consultant and other doctors and can request a medical out-patient appointment for you to attend the hospice or, if you are not well enough to attend, they can visit you at home. There is a large team of professionals who can be involved with your care if needed. This includes: social workers, complementary therapists, physiotherapists and occupational therapists. The community team can also refer you to our day services or to be admitted to one of the wards on the in-patient unit if appropriate and a bed is available.
The community team work closely with other professionals who may be involved with your care including GPs, District Nurses and hospital Consultants and nurses.
Accessing our service
Your GP, District Nurse or Hospital Team can refer you to our service. They will inform us of your illness and any problems you are experiencing which we may be able to help with. A team member will contact you to make an initial appointment with you. At this first appointment we will discuss with you the best way we can support you until these issues are resolved or addressed as best we can. To do so we may need to visit or contact you by phone for a period of time. We will ensure you have contact with other services, if required, such as your GP or District Nurse. Once we agree issues are resolved or managed as best we can, contact with our service will stop. However, if your needs change it can be accessed again if required through contact from yourself, a family member, doctor or nurse.
Hospital specialist palliative care team
If you are an inpatient in hospital most of your care will be provided by the doctors, nurses and other health professionals on your ward and led by the consultant in charge of your care. If you have a life limiting illness and have more complicated care needs you may be referred to the hospital Specialist Palliative Care Team.
They work with the doctors and nurses on your ward and provide specialist assessment and advice on many of the issues you and your family may face, such as:
- Physical symptoms, such as pain or vomiting
- Talking through treatment choices
- Coming to terms with difficult news
- Help with talking to other family members
- Practical advice on housing or benefits
- Spiritual support
- Discussing with you and planning where you would like to be cared for when you leave the hospital
- Referring you on to the hospice or community palliative care services in Leeds and beyond
A nurse or a doctor from the Specialist Palliative Care Team usually visits wards during normal office hours (Monday to Friday). Out of hours and at weekends a consultant is available to give advice to ward doctors over the telephone.
The team also delivers an extensive programme of education to many groups of staff in the hospital to raise the standards of palliative care for all who need it.
Staff members on the team include clinical nurse specialists, consultants, specialist registrars and part-time pharmacist. They receive more than 1,300 referrals per year across the five hospitals of the Trust and have no waiting list. Current figures show that 85% of patients referred have cancer as their main problem, but patients with any illness can be referred if they need specialist palliative care.
The role of the GP in palliative care
Your GP plays a vital role in caring for you and your family, and is still the person who has overall responsibility for your care.
Your GP is able to explain and answer questions regarding the nature of your illness, how it may progress and what is likely to happen in the future. They can talk to you and your family about your wishes, goals and priorities, including where you would like to be cared for. This information can be documented in an advanced care plan, which can then be shared with all the other medical professionals involved in your care, and is reviewed and changed as needed.
GPs works closely with your specialist palliative care team, district nurses and social services to make sure that your medical, psychological, social and spiritual needs are met. They ensure that your care is coordinated across all of the health and social care services, including with the medical teams who work at evenings and weekends. Your GP, and the whole general practice team, is there to support you throughout your journey.
Community matron and district nurse
Community nurses provide nursing care to patients in their own home. A significant part of their work involves caring for patients who have palliative care needs and who wish to be cared for at home (including care homes). District nursing teams work with community matrons, respiratory and heart failure nurse specialists to deliver this care to patients and supporting their carers. The aim is to ensure that patients die in their preferred place of care with dignity and symptom control achieved.
- District Nursing
The District Nurse holds a post-registration specialist practitioner qualification in providing care in the home and is the leader of a skill mixed team who work together to provide care to patients.
The District Nurse will have overall responsibility for the management of Palliative Care patients but will work closely with Community Matrons who may have been involved with caring for patients with a long term condition e.g. respiratory or heart disease, for some time.
- Community Matrons
Community Matrons work predominantly with patients who have a long term condition to help them to manage their illness and reduce the number of times they may be admitted to hospital unnecessarily. Patients may have one or more long term condition e.g. diabetes and heart failure or respiratory disease. These conditions mean that often their needs become palliative and the community matron will work with the district nursing team to ensure all the needs of the patient and carer are met.