SUMMARY

  Observations have been confined to sections dealing with choice of provision, including support of people in their own homes, Communication between clinicians and patients, support services including domiciliary support and personal care, and The impact and effect of Government Policy. Recommendations:

(a)  That consideration be given to ensuring that any recommendations given for the provision of palliative care as a result of a full comprehensive assessment should explicitly take into account the available resources, to enable the care to be successfully carried out particularly if this care is to be provided at home.

(b)  That where the location of proposed palliative care would prevent or delay this service, that regulations permit boundaries to be crossed for this purpose.

  Issues of choice in the provision, location and timeliness of palliative care services, including support to people in their own home. Within the last year, J, a man of 80 was admitted to an acute hospital outside the county where he lived with multiple problems. Palliative care was arranged at home in accordance with the wishes of the Patient. After a fully comprehensive multi-disciplinary assessment under the Single Assessment process, He was awarded fully funded continuing care, and required nursing care at home. Although all the equipment to enable him to be transferred home was provided, it was not possible to deliver the promises of care made, as no Registered Nursing was available in Domiciliary Care. Efforts to find a private nurse failed because the only organisation supplying private "hands on" nurses was just outside the County border and they could not supply the care. J died in hospital.

LOCATION

  He had to be moved to a small community hospital within his own county which delayed his discharge home. Equipment in the smaller hospital which was required included an air mattress and there was delay in getting this, because he was considered "low priority".

CONCLUSION

  Location problems, and the lack of registered nursing care at home prevented J receiving the Palliative care that had been agreed in the Comprehensive assessment.

  Communication between clinicians and patients and service provision: In the case of J, communication between Clinicians and the patient and family were excellent both in the acute hospital and the community hospital However, had the family been informed about the absence of nursing care availability at home, and had there not been the necessary delay in transfer to his home, it is possible that a different decision might have been taken with regard to the location of the Palliative care, or at least more time would have been available to arrange this.

  M, aged 80, died in an acute hospital after a stay of two months. She had superb Palliative care, and was looked after Spiritually by the Chaplain who was with her to within half an hour of her death on August Bank Holiday Sunday morning. A colleague of the Chaplain was with her when she died. In the same hospital, D aged 90, also had excellent Palliative care, and the family were kept closely informed about her condition.

  Support Services and Domiciliary care. The arrangements for these were unsatisfactory in the case of J. Instead of full care that was to be provided, there were to be two care workers three times a day and the District Nurse was to have visited only once daily. This would have put an intolerable strain on the family, most of whom lived some distance away from J's home.

  The impact and effectiveness of Government Policy. The Single assessment and Person centred care which is enshrined in Standard 2 of the National Service Framework for older people was correctly carried out with J. Had "Fair access to Care" been considered alongside the assessment a different recommendation might well have been made with regard to J's care in his final days.

  Both "M" and "D" received excellent person centred care, and at no time during the stay of all three patients in hospital was there any sign of explicit or implicit age discrimination, (Standard 1 of the National Service Framework for older people).

February 2004