Analysis

Nursing care service provides comfort and support through the night

Night time service 'helping patients to stay in their preferred place of care and in their preferred place of death'
Jessica Roberts, Jodie Barker, Mihaela Bascoveanu

Pal@home is a night nursing care service providing rapid response clinical support and short-term intervention for severely ill patients with palliative or end-of-life needs.

Guys and St Thomas NHS Foundation Trust introduced the pal@home service in December to address a shortfall in out-of-hours at-home nursing support for patients with end-of-life care needs. The service operates from 8pm to 8am, seven days a week.

The service aims to prevent unnecessary hospital admissions and to provide end-of-life care to patients at home. It compliments the work of the trusts @home service, providing patients with daytime rapid response support to prevent unnecessary hospital admissions.

Most patients are referred to the service in the last weeks, days or hours of their lives. At this difficult time, patients and families value the clinical expertise, including symptom management, and practical and personal support the nurses provide. Support can

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Pal@home is a night nursing care service providing rapid response clinical support and short-term intervention for severely ill patients with palliative or end-of-life needs.

Guy’s and St Thomas’ NHS Foundation Trust introduced the pal@home service in December to address a shortfall in out-of-hours at-home nursing support for patients with end-of-life care needs. The service operates from 8pm to 8am, seven days a week.

The service aims to prevent unnecessary hospital admissions and to provide end-of-life care to patients at home. It compliments the work of the trust’s @home service, providing patients with daytime rapid response support to prevent unnecessary hospital admissions.

Most patients are referred to the service in the last weeks, days or hours of their lives. At this difficult time, patients and families value the clinical expertise, including symptom management, and practical and personal support the nurses provide. Support can be provided over the telephone or through rapid response visits.

Referrals

The trust’s deputy head of nursing and clinical lead for pal@home and @home, Karen Titchener says night time can be particularly difficult for patients and their families but ‘knowing there is someone at the end of the phone can make all the difference’.

550,000

The approximate number of people who die in the UK each year

Patients in the London boroughs of Lambeth and Southwark can be referred to the service by GPs, including GPs from the South East London Doctors Co-operative (SELDOC), specialist palliative care services, end of life community nursing and district nursing.

Referrals can be received from care home staff, acute hospitals and the London Ambulance Service.

Those patients who are already known to the pal@home service can self-refer. Nurses visit patients at home within an hour of a telephone referral.

Nursing support

The pal@home team covers two shifts: 5pm-12am and 8pm-8am. The early team consists of a band 6 specialist nurse and a band 3 nursing assistant and the team coordinates referrals, undertakes handover and plans the night duty according to patient and carer need.

From 8pm-8am, a second specialist nurse and a senior nursing assistant provide overnight telephone support and hands-on care. The overlap of the two shifts between 8pm-12am enables the team to ensure that all patients are comfortable for the night ahead, says Ms Titchener.

‘It helps ensure everything is in place to enable patients and carers to have as peaceful a night as possible with the back-up of knowing that the service is there. If patients require help with symptom management, the nurses can reassure families that they are on hand if further care or support is needed.’

Only 21%

Proportion of people in England and Wales die at home

For safety, the nurse and nursing assistant travel together to patients’ homes. The pal@home nursing role involves administering single doses, reviewing and monitoring new symptoms and setting up and managing syringe drivers.

Clinical care includes assisting with urinary retention, blocked catheters, wound dressings and continence care. Another aspect of the pal@home nursing role involves providing support before and after death.

On average, the team makes ten patient calls and six home visits per night. Half of those visits will be between the hours of 12am-6am. The team of two staff made 20 calls, carried out 10 home visits and there were also three patient deaths.

Challenging role

The nurses quickly build a rapport with patients and families and this can make the role emotionally challenging at times. Practice development officer for the pal@home service, Debbie Robertson, says the trust provides support in dealing with emotional distress.

‘We have trainers from the Quality End of Life Care for All (QELCA) education programme who come in every month,’ says Ms Robertson. QELCA is a 5-day course, designed originally by St Christopher’s Hospice. It is followed by six work-based action learning sessions, usually held monthly.

‘The team is currently talking about the importance of debriefing situations as part of QELCA and we are looking to increase the support we provide by introducing more debriefings after the programme has ended.

'I feel it is also important for the team to debrief on the good situations where they feel they have made a positive difference as it is also a rewarding role.

‘The nurses are in a unique position to give time when it is needed most.’ said Ms Titchener.

Nurse perspective: ‘Dying at home is their last wish’

‘We are helping patients to stay in their preferred place of care and in their preferred place of death,’ says pal@home palliative care nurse, Jodie Barker.

‘The service ensures patients and their families feel supported throughout the night. We can reassure them that we will keep their family members as comfortable as possible at home. For many patients, dying at home is their last wish and we can help to make that happen.

'It is rewarding when you see patients with symptoms that are not being effectively controlled as you can quickly make a difference. Sometimes this can be all a patient needs to enable them to die peacefully at home with their family around them.

'Everyone should be able to have a good death. It makes such a difference to families that their loved one can pass away without feeling frightened or being in any pain.’

Patient perspective: ‘At her wits’ end’

Mrs A is a devoted carer to her husband, 80, who is now bed-bound and requires two people to move him due to his condition. Mr A has a longstanding degenerative illness, Pick’s disease.

40%

Proportion of people who die in hospital without it being it clinically necessary for them to be in hospital

The couple, who have been married for 60 years, have five children and grandchildren and great-grandchildren. Mr A was initially referred to the pal@home team by the community end of life nursing team for practical support and symptom management as he was feeling nauseous.

After being introduced to the service, Mrs A subsequently rang the pal@home team for urgent support. She reported that she was at her wits’ end’ and out of her depth as her husband was very ill and vomiting. The pal@home team attended to administer an anti-emetic and to support Mr A’s hygiene needs.

Mrs A was distressed and admitted she had not known where to turn, except that she had used pal@home before and felt able to call them. As it was after 8pm, Mrs A felt that without the pal@home service she would have had to call for an ambulance as Mr A was lying in his own vomit, which may have resulted in a hospital admission. She now describes the pal@home team as being her ‘angels of the night’.

Julie Penfold is a freelance journalist

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