Palliative and end of life care over winter 2023-2024

Update for health and social care professionals

Plans are underway across Cornwall and the Isles of Scilly to offer more health and care services from people’s home and supported in local communities this winter as per peoples’ wishes.  

The aim is that we all deliver the right care, in the right place and at the right time for our residents. 

Those coming to the end of their lives are amongst the most vulnerable in our communities. As health and care staff, there are things we can do to best support people to remain safe and well cared for in their preferred place of care.

Early identification of those in last year of life

Identifying those who may be entering their last year of life, can enable more proactive, supportive care and keeping people where they want to be for their final months, weeks or days of life.

The Gold Standards Framework Proactive Indicator Guidance (or Supportive and Palliative Care Indicator Tool) are useful tools to help guide clinical teams to correctly identify those coming to the end of their lives.

The community specialist palliative care nurses will be supporting GP practices this winter, to help check whether all those who may be approaching the last year of life have been correctly identified, have the relevant code attached to their notes (‘Palliative Care’ or ‘End of Life Care’), and have been offered the appropriate personalised care, advance care planning or treatment escalation plans.

This is being supported within RCHT where specialist palliative care services have joined with eldercare to launch the GREAT discharge initiative. This focuses on improving discharge communication to include information relevant to end of life care planning.

Personalised care, advance care planning and treatment escalation plans

Personalised care planning, advanced care planning and treatment escalation plans are vital to ensuring that patients get the right care, at the right time, in the right place, by the right person. Help support what matters to those you are caring for by offering, formalising and reviewing care plans that are personalised to the individual. 

Think- if you did not know the person, and they couldn’t communicate their wishes, would the care plan/TEP form help guide an appropriate decision about that persons care? Is the care plan/TEP stored in a place that your colleagues can find this information in a hurry?

Out of Hours palliative care line

A reminder that Kernow Health offer an out of hours number for patients/carers on 01872 224050. This number helps prioritise palliative care patient calls and ensures the person gets the right care at the right time.

Specialist palliative care advice

The specialist palliative care advice line is available to healthcare professionals 24hrs a day, 7 days a week on 01736 757707. Incoming calls are dealt with by an administrator 9.00am – 5.00pm Monday to Friday.

Outside of these times the call will be directed to the national Supportive Care UK team, where a palliative care consultant will be able to provide advice. 

Please ensure that you have the relevant clinical information available, and an appropriate review has taken place prior to calling the advice line.

Coming soon

• Treatment Escalation Plans – Cornwall are moving to the Devon and Cornwall TEP. Keep an eye out for further communication soon. 
• Orange folders – 2000 ‘what matters to me’ orange folders will soon be in circulation across Cornwall following a successful pilot. These folders enable patients to keep their important health documents such as advance care plans, TEP forms and personalised care plans in one hand held, brightly identified folder. An update will be provided through the palliative and end of life care website when available. 
• End of life care bags – Bags with a short-term supply of essentials in the last days of life are being compiled and supplied to key areas such as community nurses, relevant hospital teams, and out of hours. The supplies are there to help carers care for their loved one in a time of crisis at the end of life.