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Rapid response end of life care team offers opportunities for band 6 nurses and HCAs

Karen Titchener discusses her new service and the work of nurses who give overnight palliative care in patients’ homes.

Karen Titchener discusses her new service and the work of nurses who give overnight palliative care in patients’ homes

Picture credit: David Tett

When Karen Titchener helped launch an out-of-hours end of life nursing team she saw an opportunity to reduce gaps in the service as well as potential for her own role.

The deputy head of nursing and clinical lead at Guy’s and St Thomas’ NHS Foundation Trust, London, is enthusiastic about the benefits the programme has brought.

The pal@home service, which began in December, is a rapid-response nursing care service. It provides prompt clinical support and short-term intervention from 8pm to 8am, seven days a week.

‘We are helping patients to die in their preferred place, ensuring they and their families feel supported, and we are meeting their needs through faster responses. It is giving them what they wouldn’t otherwise have,’ says Ms Titchener.

Nurses visit patients at home in the London boroughs of Lambeth and Southwark within an hour of telephone referral. The team receives between two and six calls every night and averages 100 referrals a month. The service complements the work of the trust’s @home service, which enables patients to continue their recovery at home or avoid a hospital stay altogether.

Ms Titchener says there were some gaps in service provision previously, and scope for providing better overnight end of life care. For families, nights can be particularly isolating, she says, so knowing there is someone at the other end of a phone, or who is happy to come out, can make all the difference.

Pal@home nurses are supported by the trust to learn about the new role. There is a full induction programme, including a two-day course, Transforming End of Life Care. In addition, training is provided in dealing with emotional distress as well as for working out of hours in a community.

Ms Titchener says nurses who join the team are drawn to the role for a variety of reasons. For some, night shifts fit into their family schedules, while for others the opportunity to work as an autonomous practitioner is an attractive option. Coupled with seeing patients and relatives at a vulnerable time, and being able to give patients a good death, means the role can be a rewarding one.

She adds: ‘No task is too menial when you’re supporting someone at the end of life – it’s about giving the best you can.’

Her role in delivering a new service has enabled Ms Titchener to draw on her experience, learn to be more politically astute and enhance her career progression.

She emphasises that working in end of life care is not a soft option and would not suit every nurse. ‘It’s not laid-back, hot chocolate and slippers. You have to be open to anything that comes along,’ she advises. ‘There has to be a rapid response because patients are in pain. We don’t have a predicted caseload, so it’s not for everyone.’

Providing this care is about being sensitive to the emotional needs of the family, Ms Titchener explains. ‘Families enjoy that support and exchange. Instead of giving an injection and walking off, you should consider whether the patient is comfortable. What you don’t want is to be called an hour later because what you’ve done hasn’t worked.’

Possessing emotional intelligence is crucial. Some family members can be distressed at the ‘finality’ of seeing nurses in their homes, but 90% of families want that support, according to Ms Titchener. ‘They’re not experts and they don’t want to see their loved one suffer. That’s why all these teams have to communicate together, to know all the idiosyncrasies that are going on in the home environment.’

What the pal@home role involves

Band 6 nurses are recruited along with band 3 staff. For safety, they travel together to patients’ homes where they are responsible for:

Looking after a deteriorating patient.

Providing support before and after death.

Nursing care and offering comfort.

Administering stat doses of medication.

Reviewing and monitoring new symptoms.

Setting up and managing syringe drivers.

Clinical care, including urinary retention, blocked catheter, wound dressings, continence care.

Settling newly discharged patients.

Receiving referrals from GPs, care home staff, acute hospitals, community matrons, district nurses and the ambulance service.

Developing staff’s advanced assessment skills.

While an understanding of acute illness and two years’ experience in bereavement care, symptom management and nursing in multiple fields is desirable, good communication is the skill most needed by an end of life nurse, Ms Titchener says.

Guy’s and St Thomas’ matron and clinical practice development facilitator, Jose Facultad says: ‘When you only look after people who are dying, it can become oppressive. But if you have a team you can debrief with, then you can talk together and get it out of your system.’

Every morning there is a verbal handover to the end of life community team or the pal@home service to ensure everyone is kept up to speed. This is valuable for staff, who may be experiencing emotional turmoil.

Working in the community means there can be unscheduled requests at short notice, so the ability to think critically is vital.

Ms Titchener says this means making judgements about the presenting problem. ‘Who’s going to be safe, who can safely wait, who’s going to call for an ambulance and be inappropriately taken to hospital?’

Getting end of life care right can be extremely rewarding, and as Ms Titchener says, over time, it may need to grow.

‘It’s about being responsive to meet the needs of the community – whatever that involves’.

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