A guide to services providing palliative care at home Many people living with a life-limiting illness will have lots of different health and social care professionals involved in their care. This guide describes the roles of the different professionals to make it easier for you and your family to understand who is involved, what their role is and where to get help and support, should you need it. With your permission, the different professionals involved in your care will communicate with you and with each other as needed, to ensure that everyone knows the current situation and plan. General Practitioners (GPs) GPs are responsible for the medical care of people living in their own home or in a care home. GPs work with other health care professionals such as district nurses, community matrons, specialist hospital and hospice teams, physiotherapists, dietitians and clinical nurse specialists to provide the best care for each person. Your GP will: assess your symptoms and prescribe medicines and other treatments to manage them seek expert advice from specialists when required provide information on your condition and the support services available to you liaise with the district nurse regarding yourcare at home District Nurses (DNs) If your illness means that you can no longer leave your house or care home (that is a home without registered nursing) for appointments or treatment, then a district nurse can help to arrange your care. District nurses may monitor skin conditions,administer medicines, change dressings, manage symptoms and order equipment to make caring for patients at home easier (for example, a hospital bed or a commode), amongst other tasks. District nurses also coordinate the other services that you might require, which can include community nurses, health care assistants, care workers, Marie Curie Nurses for night-sitting (see below), or other care agencies. District nurses provide a 24/7 service and work with you and those important to you to prepare a personal care plan. Social care Social services can organise non-medical care. This includes things like having meals delivered, adaptations to your home, and help with washing, dressing and eating. A social worker or another trained professional provided by the local social services department can assess your suitability for this type of care and help organise it. Social services can also help when someone needs to move into a care home. If you have a family member or friend looking after you (an informal carer), social services might be able to help them to get support as well. They can talk to them about their own needs. Support might include putting them in touch with local support groups, help with taxi fares if they don’t drive, and getting someone to take over caring for a while so they can take a break (respite care). Royal Trinity Hospice Specialist Palliative Care team The team at Trinity provides specialist palliative nursing and medical care. We will assess you and talk to your family or carers to provide the best care and support based on your needs. This holistic approach is delivered by a multidisciplinary team (MDT) and can involve different health care professionals from the hospice, each with specialist training and experience. This includes doctors, nurses, occupational therapists, physiotherapists and a patient and family support team, including counsellors. Most of the care and support Trinity provides is to patients and their families at home. Most homebased care and support is delivered by the nurse specialists, but you may be supported by different members of the MDT depending on your individual circumstances. The team will identify which other professionals are already involved in your care and work closely with them to support with any complex physical, psychological, social or spiritual needs that you have as a result of your life-limiting diagnosis. At Trinity, there is a 28 bedded inpatient unit (ward) where you may be admitted if your symptoms are complex and are difficult to manage at home, or if you are dying and would prefer to die at Trinity. Patients can be admitted directly from home or may be transferred from a hospital. The hospice is not a long-term facility so we may talk to you about transferring your care back toyour home or nursing home. Royal Trinity Hospice is an independent charity with only a small percentage funded by the NHS but allof the nursing and medical care we give is free. Macmillan nurses and other specialist nurses Macmillan Cancer Support funds a range of professionals to support people affected by cancer. Macmillan nurses are usually based inhospital and work alongside cancer specialists. They will support you to cope with your diagnosis and provide information regarding treatment options. Macmillan nurses are a key contact between you and your specialist cancer team and will support you throughout your treatment. They don’t carry out routine nursing tasks, but they may call you or see you at hospital outpatient appointments or if you are admitted to hospital. If you have an illness other than cancer you may get support from specialists who are experts in conditions such as motor neurone disease (MND), heart failure, chronic respiratory disease, multiple sclerosis (MS) or Parkinson’s disease. Marie Curie nurses Marie Curie nurses or health care assistants usually provide overnight care for a shift of 8 or 9 hours, usually when someone is in the last weeks or days of life. Whilst they are in the home, Marie Curie nurses will help manage symptoms, provide nursing care and support with medicines. They will also provide emotional support to you and your family and friends. They will assess your needs and inform the District Nurses of any changes so they can plan any kind of additional help you may need. Like Trinity, Marie Curie is astandalone charity and care is usually organised through referral by your DN or Specialist Palliative Care Nurse. It is not possible to include all services available here and there is likely to be variation depending on where you live within our catchment area. If you have a question about something you or your family member needs, please do not hesitate to contact us on0207 787 1062. We will put you in touch with the appropriate professional at the hospice, or signpost you to another team who can help. 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