Topic 9 - Specialist Palliative Care Standards 160304

Specialist palliative careL Cunnington – Updated 3 March 2004

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TOPIC 9 - THE SPECIALIST PALLIATIVE CARE TEAM (MDT)

Introduction

The National Institute for Clinical Excellence has developed Guidance on Supportiveand Palliative Care for patients with cancer. The standards under this topic arederived from the NICE recommendations in chapter 3 Co-ordination of Care and 7Specialist Palliative Care Services.

A significant number of people with advanced cancer suffer from a range of complexproblems – physical, psychological, social and spiritual – which cannot always bedealt with by generalist services in hospitals or the community. Much less frequently,people with early (curable) cancer may experience a similar range of problems andmay benefit from specialist input. Their families and informal carers may also needexpert support during their lives and in bereavement.

A range of core specialist palliative care services is required to meet these needs.Core services may be provided by the NHS and/or by the voluntary sector.

Definition of Palliative Care

NICE employs the following definition of palliative care which is based on the 1990WHO definition. Palliative care is:

“…… the active holistic care of patients with advanced, progressive illness.Managements of pain and other symptoms and provision of psychological, social andspiritual support is paramount. The goal of palliative care is achievement of the bestquality of life for patients and their families. Many aspects of palliative care are alsoapplicable earlier in the course of the illness in conjunction with other treatments”.

Palliative care is based on a number of principles, and aims to:

• Affirm life and regard dying as a natural process.• Provide relief from pain and other symptoms.• Integrate psychological and spiritual aspects of care.• Offer a support system to help patients to live as actively as possible until

death.• Offer a support system to help the family cope during the patient’s illness and

in their own bereavement.

Palliative care is the responsibility of all health and social care professionals and isdelivered by two distinct categories of staff:

• The patient and carers’ usual professional carers.• Professionals who specialise in palliative care, some of whom are accredited

specialists.

Relation to Cancer Networks

The NICE guidance on supportive and palliative care recommends that (paragraph1.12), Strategic Health Authorities should ensure structures and processes are in placeto plan and review local supportive and palliative care services. In this manual, forease of reference, such structures are referred to as the “palliative care network”.


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They will be considered as, and peer reviewed as, an integral part of a named hostcancer network.

In practice the details of such structures and the names they are given may vary fromone cancer network to another. This is not subject to assessment provided thestructures are put forward for review against these standards in “cancer networks,palliative care specific standards”.

At the current time, caring for patients with cancer comprises a very large part of theworkload of supportive and palliative care providers, although it is recognised thatthis may change with time. For this reason, the NICE guidance has been developedon the basis that supportive care and palliative care will be organised within thecancer network model and reviewed as stated above, within a given cancer network’scancer peer review process.

Malignant and Non-Malignant Disease

Although part of the palliative care service’s activity is directed to patients who sufferfrom non-malignant disease, the standards apply to the service irrespective of whetherthe patients they are dealing with at a given time suffer from cancer or non-malignantdisease. If some palliative care services or facilities specialise entirely in non-malignant disease, they should discus with the zonal peer review team whether theyshould be put forward for assessment.

Relationship To Other Cancer Services Within The Cancer Network

Palliative care is offered across NHS hospitals, voluntary sector and communitysettings. All of these settings will be subject to the standards and peer review. Theydo not necessarily coincide with a given network’s way of organising the rest of itscancer services. This will be addressed as follows:

Regarding the palliative care network as defined above, much of its constituentpalliative care services and teams will have similar catchments to the “local” or“secondary” catchments for the rest of cancer services, of the hospitals in theirvicinity. It will then be self-evident that the cancer network to which these hospitalsand cancer services belong is the cancer network which the collection of specialistpalliative care teams in question, are an integral part of. They should be considered asthe palliative care network of this particular cancer network and should be reviewedas part of this cancer network’s review.

However, some teams (often voluntary sector and community-based ones) happen toserve a catchment population which is divided between more than one Cancernetwork for the rest of cancer services. These teams should be reviewed as part ofonly one cancer network. See the following for an illustration of this and of itsimplications.


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Cancer Network A Cancer Network B

1, 2, 3: Catchments of specialist palliative care teams.

Team 1: Reviewed as part of cancer network A’s, palliative care network.

Team 2: Reviewed as part of cancer network B’s, palliative care network.

Team 3: A decision has to be made and agreed with networks A and B, on whichsingle cancer network’s palliative care network it will join and be peer reviewedunder. The team’s clinical and referral guidelines should, as far as possible, beuniform and consistent with those of the single, chosen host cancer network. Someaspects of practice in part X, may have to be different from part Y, if localcommissioners are different and similar agreements cannot be reached. This shouldbe avoided if possible and is a matter for negotiation and then agreement by thechosen host network.

Referral contact points may well differ for certain highly localised services betweenparts X and Y. This should be dealt with in referral guidelines and is a matter ofcommon sense.

At local level, an individual specialist palliative care team may function in settingswhich may over-arch NHS hospitals, the community and the voluntary sector. Thismay make it difficult to organise the specialist palliative care services across thenetwork in a way which is coterminus with the local divisions into which the rest ofcancer services are organised. The standards require that the latter are organisedpragmatically into portions defined by the network according to the direction ofpatient flow and concentrations of population and facilities. These are termed“localities” and are more flexibly defined than previous cancer centres or cancer unitsalthough established centres and units would also comply as localities.

For the purposes of local management and organisation, specialist palliative careservices should similarly be pragmatically divided into portions which the networkagrees are appropriate according to patient flow and the concentrations of populationand facilities. For the purposes of the standards and peer review, those portions aretermed “areas”. As explained above, they may not naturally coincide with thelocalities as defined for the rest of cancer services, particularly when considering thecatchments of some voluntary sector hospices. This is not subject to assessment. It isstrongly recommended, however, for clarity of management and organisation that the“localities” of cancer services and the “areas” of specialist palliative care are definedso as to be as coterminus as possible or at least to map simply onto each other.

1 2

3X Y


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Geographical Extent and Level of Service Provisions

The national guidance on certain specific cancer types results in definite levels ofservice provision expressed in terms of catchment populations or case workload forindividual MDTs. It is also determined to some extent for all cancer types by therequirement that new patients should not be referred for definite anti-cancer treatmentoutside MDTs. The situation is not yet so clearly defined for the provision ofpalliative care to patients by specialist palliative care teams. Such patients may onoccasion bypass the team entirely. The eventual aim is to provide the service at alevel determined by population-based needs assessment. This principle is included inthe standards but will not be fulfilled by some networks by the time of their peerreview. As an interim standard therefore, it is required that all parts of the networkand all settings for palliative care are covered by a named specialist palliative careteam. The size of a given team’s “patch” will not be subject to a limit. In order toassess the degree of coverage by teams, the network is required to name thecatchments and palliative care settings which it encompasses and each team isrequired to do the same.

Building The Palliative Care Network

The above considerations give rise to the following process of building (or if it isalready in operation, “clarifying and defining”) the cancer network’s palliative carenetwork. The responsibility for this lies with the network palliative care group, andwith the board.

(i) Agree the catchments and care settings encompassed by the palliative carenetwork.

Note:

The catchments and care settings will be expressed in terms of named NHShospitals/hospices, voluntary sector hospitals/hospice and communitiesdefined by their respective, named PCTs.

(ii) For specialist palliative care teams covering catchments and care settingswhich span more than one cancer network for other cancer services, agreewhich single cancer network’s peer review they will be assessed under andtherefore, effectively, which single cancer network they belong to.

(iii) Agree the areas (as defined above) into which the palliative care network willbe divided.

Agree for each area, the catchments and palliative settings which it encompasses, andwhich teams cover it.

Assessing Specialist Palliative Care

• The cancer network board’s responsibilities in relation to specialist palliative careare assessed by applying the standards on palliative care in topic …… section 1,to the board and compliance counts toward the board’s overall performance.


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• The network palliative care group’s responsibilities are assessed by applying thestandards in topic …… section …… to the group, and compliance counts as thenetwork palliative care group’s performance.

• The responsibilities of the specialist palliative care teams are assessed by applyingthe standards in topic …… to each individual team in the network. Compliancecounts as each individual team’s performance.


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The standards in this topic should be applied to each specialist palliative careMDT and the results of their compliance count as the MDTs assessment.

Objectives • To ensure that designated specialists work effectively together in teamssuch that decisions regarding all aspects of diagnosis, treatment andcare of individual patients and decisions regarding the team’soperational policies are multidisciplinary decisions.

• To ensure that care is given according to recognised guidelines(including guidelines for onward referrals) with appropriateinformation being collected to inform clinical decision-making and tosupport clinical governance/audit.

STANDARD &LEVEL

STANDARD DEMONSTRATION OFCOMPLIANCE

MDT LEADERSHIP

The responsibility for assessment purposes for standards …. to … lies with the area lead clinicianfor palliative care.

Standard

Level 1*

There should be a single namedpalliative care lead clinician for theteam, who should be a core member ofthe team.

Notes:They may be from any clinicalprofession.

They may be the area palliative carelead clinician.

The named clinician for theMDT, agreed by the area leadclinician for palliative care.

Note:If the team lead and the arealead are the same individual,this should be agreed by thenetwork palliative care groupchair.

Standard

Level 1*

The team lead clinician for palliativecare should have agreed theresponsibilities of the position with thearea lead clinician.

Note:The role of lead clinician of the MDTshould not of itself implychronological seniority, superiorexperience or superior clinical ability.

The written responsibilitiesagreed by the team lead and thearea lead (or the network groupchair, where the team and arealead are the same individual).

Note:The exact nature of theseresponsibilities are not subjectto assessment, save as per thestandard. See approx at end oftopic… for an illustration ofthe responsibilities of this role.

The responsibility for assessment purposes for standards … to … lies with the specialistpalliative care team lead clinician.


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STANDARD &LEVEL


TEAM CRITERIA

Standard

Level 1*

The MDT should be listed as part ofthe services of a named locality ofthe network.

The list of services of thelocality.

MDT STRUCTURE

Standard

Level 1*

The MDT should provide the namesof core team members for namedroles in the team.

They should include:

• Palliative medicine specialist.• Palliative care nurse specialist.• MDT co-ordinator/secretary.

Notes:Where a medical speciality isreferred to, the core team membershould be a consultant. The coverfor this member need not be aconsultant. Where a medical skillrather than a speciality is referred to(e.g. colonoscopy in the case ofcolorectal MDTs) this may beprovided by one or more of the coremembers or by a career grade non-consultant medical staff member.

The medically qualified coremember(s) depend on the cancer siteof the MDT.

The coordinator/secretary role needsdifferent amounts of time dependingon team workload. See the appendix……for an illustration of theresponsibilities of this role. The co-ordinator and secretarial role maybe filled by two different namedindividuals or the same one. It neednot occupy the whole of anindividual’s job description. Theresponsibilities/job description arenot subject to assessment save as perthe standard.

The name of each core teammember agreed by the leadclinician of the MDT.


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STANDARD &LEVEL


There may be additional coremembers agreed for the team besidesthose listed above. This is notsubject to assessment.

MDT MEETINGS

Standard

Level 1*

The MDT should hold its meetings,as described in standard …, weeklyand record core members’attendance.

The programme of datedmeetings.

Attendance records of themeetings.

Standard

Level 1*

Core members or their arranged“cover” (see standard …) shouldattend at least half of the number ofmeetings.

The attendance record of theMDT.

Note:The intention is that coremembers of the team should bepersonally committed to it,reflected in their personalattendance at a substantialproportion of meetings, notrelying instead on their coverarrangements. Assessorsshould use their judgments onthis matter and shouldhighlight in their report wherethis commitment is lacking.

Introduction

This next standard is essentially the same as the previous standard but set at a lower priority levelwith the attendance at two thirds instead of one half.

Standard

Level 1

Core members or their arranged“cover” (see standard …) shouldattend at least two thirds of thenumber of meetings.

The attendance record of theMDT.

Note:The intention is that coremembers of the team should bepersonally committed to it,reflected in their personalattendance at a substantialproportion of meetings, notrelying instead on their coverarrangements. Assessorsshould use their judgments onthis matter and shouldhighlight in their report wherethis commitment is lacking.

Standard The MDT should agree cover Written arrangements agreed


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STANDARD &LEVEL


Level 1* arrangements for each core member.

Note:Where a medical specialty is referredto the cover for a core member neednot be a consultant but if not, shouldbe a specialist registrar or staffgrade.

It is recommended, however thatwhere an MDT has a single coremember who is a consultantpalliative medicine specialist, coverarrangements are agreed with aconsultant palliative medicinespecialist from another team.

by the lead clinician of theMDT.

Note:The actual arrangements andjudgements on theirappropriateness are notsubject to assessment save asin the note opposite.

EXTENDED TEAM

Standard

Level 1*

If they are not already offered as coreteam members the named team forthe extended MDT should include:

• Clinical psychologist.• Social worker.• At least one person agreed as

representing care for patients’and carers’ rehabilitation needs.

• At least one person agreed asrepresenting care for patients’and carers’ spiritual needs.

• At least one person agreed asrepresenting bereavement care tofamilies and carers.

• Oncologist.• Anaesthetist with expertise in

nerve blocking and neuro-modulation techniques.

• Pharmacist.

Note:The MDT may wish to nameadditional extended team members.These are not subject to assessment.For illustrative purposes only,additional team members which havebeen recommended include;dietician, speech and languagetherapist, providers ofcomplementary therapies and

The name of each extendedteam member agreed by thelead clinician of the MDT.

Note:The exact constitution of theextended team and judgementsover its appropriateness arenot subject to assessment saveas per the standard.


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STANDARD &LEVEL


creative activities.

OPERATIONAL POLICIES

Standard

Level 1*

Besides the regular meetings todiscuss individual patients, the teamshould meet at least annually todiscuss, review, agree and record atleast some operational policies.

Minutes of at least one meetingagreed by the lead clinician ofthe MDT to illustrate therecording of at least someoperational policies.

Standard

Level 1*

There should be an operationalpolicy, whereby all new patients towhom any members of the MDTintend to offer care or advice shouldbe discussed by the team at the firstavailable team meeting, as perstandard …

Note:The MDT may in its network referralguidelines, intend to discuss patientsat additional times to the above i.e.in addition to when they are newlypresenting to the team. This is notassessed under this standard, but isaddressed by the referral guidelines.

The written operational policyagreed by the lead clinician ofthe MDT.

Note:The contents of the policy arenot subject to assessment saveas per the standard.

Standard

Level 1*

There should be an operationalpolicy whereby, a single named keyworker for the patient’s care at agiven time is appointed from theMDT members, for each individualpatient, and the name of the currentkey worker is recorded in thepatient’s case notes. Theresponsibility for ensuring that thekey worker is appointed should bethat of the nurse MDT member(s).

Note:For information:- according to theNICE palliative care guidance thekey worker is a member of the teamresponsible for the lead on co-ordination within the team of care ofan individual patient and acting inthe capacity of single commonadministrative contact for thepatient, carers and MDT.

The written policy agreed bythe lead clinician of the team.

Note:The contents of the policy arenot subject to assessment saveas per the standard.

Standard

Level 1

The above policy should have beenimplemented for patients who cameunder the MDTs care after

Assessors should spot checksome of the relevant patients’case notes.


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STANDARD &LEVEL


publication of these standards andwho are under their care at the timeof the peer review visit.

Standard

Level 1

The core imaging specialist shouldregularly report on imaging of theprimary care site or sites of theMDT, by modalities agreed as instandard ….

The assessors should enquireas to the working practice ofthe core members’ imagingdepartment.

Standard

Level 1

24-Hour Telephone Advice ServiceThe MDT should agreed to thepalliative care network’s servicespecification for the 24-hourtelephone advice service (seestandard …) and specify the staffmembers which it provides for therelevant rota.

The service specificationagreed by the lead clinician ofthe MDT specifying the staffprovided for the relevant rota.

Standard

Level 1

0900-1700 Hours Visiting ServiceThe MDT should agree to thepalliative care network’s servicespecification for the 0900-1700hours visiting service (see standard…) and specify the staff memberswhich it provides for the relevantrota.

The service specificationagreed by the lead clinician ofthe MDT specifying the staffprovided for the relevant rota.

SPECIALIST PALLIATIVE CARE MDT NURSE MEMBER STANDARDS


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STANDARD &LEVEL


Introduction

Why are there currently “nursing standards” for MDTs, but no similar requirements for otherMDT members?

(i) The modern change to MDT working has created and then highly developed the specificrole of nurse MDT member, with its related activities which, in full measure, go to makeup the role of cancer nurse specialist. The roles of the medical specialties in the MDThave not been so profoundly influenced or so extensively developed by their MDTmembership itself, compared to that of the MDT nurse member. The role definitions andtraining requirements of nurse MDT members are not very well “officially” establishedoutside the MDT world in contrast to the well defined medical specialties with theirformal national training requirements (e.g. there were thoracic surgeons and palliativecare physicians, before there were established lung MDTs and specialist palliative careteams).

Therefore a particularly strong need was perceived for using the standards to define moreclearly the role of the nurse member and to set out minimum training requirements fornursing input into MDTs. This is in order to establish these roles more firmly in the NHSinfrastructure, and to avoid the situation where MDTs can comply with standards byhaving generalist nurses who “sit in” on MDT meetings and sign attendance forms butplay no defining role in the team’s actual dealings with its patients.

(ii) There has been a marked desire to incorporate training in communication skills into thesenursing standards. However this is balanced by an equally marked difficulty in definingthe boundaries of what might be considered as communication skills. Related to this isthe problem that nursing courses in general oncology, cancer site specific oncology andspecialist palliative care may overlap considerably with training in communication skills.Both these difficulties are addressed in the standards.


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STANDARD & LEVEL STANDARD DEMONSTRATION OFCOMPLIANCE

Standard

Level 1*

The MDT should have at least one corenurse member who should have enrolledin, or be undertaking, a programme ofstudy in nursing practice which has beenaccredited for at least 20 level III CATpoints and which incorporates module(s) inspecialist palliative care.

Notes:For this round of peer review, core nurseMDT members who have previouslycompleted ENB courses which includemodule(s) in specialist palliative care areconsidered to be compliant with thisstandard and standard ….

Nurses who are enrolled in or undertakingtraining for qualifications which may be ofequal or greater academic professionalstanding to that defined in the standardand which include specialist palliativecare, may be considered compliant andthey should discuss this with the assessors.

It is strongly recommended that if there ismore than one core nurse member in theMDT, they should all be compliant withthis standard. This is not subject toassessment, however.

It is anticipated that for subsequent peerreview rounds, all core nurse members willneed to be compliant with this standard.

The assessors shouldenquire of course startdates and the coursesbeing undertaken.

Standard

Level 1

The MDT should have at least one corenurse member who should havesuccessfully completed a programme ofstudy in nursing practice which has beenaccredited for at least 20 level III CATpoints and which incorporates module(s) inspecialist palliative care.

Notes:Compliance with this standardautomatically confers compliance withstandard…..

It is strongly recommended that if there ismore than one core nurse member in theMDT, they should all be compliant with

The certificate ofsuccessful completionof the course.


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this standard. This is not subject toassessment, however.

Nurses who already hold qualificationswhich may be of equal or greateracademic/professional standing to thosedefined in the standard and which includespecialist palliative care may beconsidered compliant and they shoulddiscuss this with the assessors. Thisincludes qualifications which pre-date theCAT points system.

Standard

Level 1*

The MDT should have at least one corenurse member who should have enrolled inor be undertaking a course incommunication skills, which is accreditedfor CAT points.

Notes:Nursing courses compliant with standard… would be considered compliant with thisstandard if they contained module(s) incommunication skills (as defined below)which are accredited for CAT points.

For the purposes of peer review, courses inthe following areas of practice, accreditedfor CAT points are compliant, as well ascourses covering generic communicationskills:

Counselling, breaking bad news,bereavement counselling and courses inthe practice of any of the psychologicaltherapies.

Nurses who are enrolled in, or undertakingtraining in those areas leading to first orhigher degrees, will be compliant (as thesewill be accredited for CAT points).

It is strongly recommended that if there ismore than one core nurse member in theMDT, they should all be compliant withthis standard. This is not subject toassessment, however. It is anticipated thatfor subsequent peer review rounds, allcore nurse members will need to becompliant with this standard.

The assessors shouldenquire of course startdates and the coursesbeing undertaken.


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Standard

Level 1

The MDT should have at least one corenurse member who has successfullycompleted a course in communicationskills which is accredited for CAT points.

Notes:Nursing courses compliant withstandard… would be considered compliantwith this standard if they containedmodule(s) in communication skills (asdefined below) which are accredited forCAT points.

For the purposes of peer review, courses inthe following areas of practice, accreditedfor CAT points are compliant, as well ascourses covering generic communicationskills.

Counselling, breaking bad news,bereavement counselling and courses inthe practice of any of the psychologicaltherapies.

Nurses who have previously obtainedtraining qualifications in any of theseareas and which pre-date the CAT pointssystem and which may be of equal orgreater academic/professional standingthan those outlined in this standard, maybe compliant and they should discuss thiswith the assessors. It is stronglyrecommended that if there is more thanone core nurse member in the MDT, theyshould all be compliant with this standard.This is not subject to assessment, however.It is anticipated that for subsequent peerreview rounds all core nurse members willneed to be compliant with this standard.

Compliance with this standardautomatically confers compliance withstandard ….

The certificate ofsuccessful completionof the course.

Standard

Level 1*

The MDT should have agreed a list ofresponsibilities with each of the core nursemembers of the team, which includes thefollowing:

• Contributing to the multi-disciplinarydiscussion and patient

The list ofresponsibilities agreedby the lead clinician ofthe MDT and the corenurse members.


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assessment/care planning decision ofthe team at their regular meetings.

• Providing expert palliative carenursing advice and support to otherhealth professionals providingpalliative care.

• Involvement in clinical audit.• Leading on patient communication

issues and co-ordination of thepatient’s pathway for patients referredto the team; acting as the key workeror being responsible for nominatingthe key worker for the patient’sdealings with the team.

Note:Additional responsibilities to those in thisstandard and the next standard may beagreed. This is not subject to assessment.

Standard

Level 1

The MDT should have agreed a list ofresponsibilities with at least one of the corenurse members of the team, which, inaddition to the items listed in standard ….,includes:

• Contributing to the management ofthe service (see note below).

• Utilising research in the nurse’sspecialist area of practice.

Notes:“Management” in this context does notmean clerical tasks involving thedocumentation of individual patients i.e.this responsibility does not overlap withthe responsibility of the MDT co-ordinator.

A list of responsibilities containing all theelements in this and the previous standardwould encompass all of the four domainsof specialist practice required for the roleof nurse specialist.

Additional responsibilities to those in thisand the previous standard may be agreed.This is not subject to assessment.

The job descriptionagreed by the leadclinician of the MDTand the relevant corenurse member.


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STANDARD & LEVEL STANDARD DEMONSTRATIONOF COMPLIANCE

FUNCTIONS OF THE TEAM

Providing Patient Centred Care

Introduction

See also, the following standards which deal with this issue, but are included elsewhere:• The network policy on information for patients (standard ……)• Operational policy on the key worker (standard …. and for specialist palliative care

MDTs standard …).• Distribution of communication guidelines to all MDT members (standard ….)• Distribution to all MDT members of the guidelines on patient assessment and palliative

and supportive care in specific situations (standard …..)• The team member nominated to have responsibility for information for patients’ and

users’ issues (standard …)

Standard

Level 1*

Arrangements should be agreed (in additionto the initial clinic consultation in which thetreatment planning decision iscommunicated to the patient), such that, ifnecessary, patients and/or carers may gainaccess to members of an MDT to discussproblems or concerns.

Written arrangementsagreed by the leadclinician of the MDT.

Standard

Level 1*

The MDT should have started to offerpatients the opportunity of a permanentrecord or summary of at least a consultationat which the treatment options of theirdiagnosis were discussed.

Note:The MDT may, in addition, offer apermanent record of consultationsundertaken at other stages of the patient’sjourney. This is not subject to assessment.

The assessors shouldenquire of the workingpractice of the teamand see examples ofrecords given topatients.

Note:The detailed contentsand methods ofobtaining it orproviding it are notsubject to assessment.It is recommendedhowever, that they areavailable in languagesand formatsunderstandable bypatients includinglocal ethnic minoritiesand patients who arenot fully able. Thismay necessitate theprovision of visualand audio material.


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Standard

Level 1*

The MDT should have undertaken or beundertaking a survey of its patients’experience of the services offered by theteam.

The survey should at least ascertain whetherpatients were offered:

• A key worker.• The MDT’s information for patients

(written or otherwise).• The opportunity of a permanent

record or summary of a consultationat which their treatment options werediscussed.

Note:There may be additional items in the survey.This is not subject to assessment but it isrecommended that other aspects of theirexperience are covered.

The survey results(complete or inprogress).

Note:The content of theresults are not subjectto assessment save asper standards…. and…..

Standard

Level 1

If the survey in ….. has been completed theteam should have presented and discussedits results at an MDT meeting and shouldhave agreed at least one action point arisingfrom the survey.

Extract of minutes ofthe MDT meeting.

Standard

Level 1

If the survey in …. has been completed andpresented at an MDT meeting the teamshould have implemented at least one actionpoint arising from the survey.

Assessors to enquireof actions taken.

Standard

Level 1*

The MDT should provide written materialfor patients which includes:

• Information about patient self-helpgroups if available and complyingwith the network quality criteria.

• Information about the servicesoffering psychological, social andspiritual/cultural support, ifavailable.

The written (visualand audio if used - seenote below) material.

Notes:Its contents andformat are not subjectto assessment save asper the standard. It isrecommendedhowever that it isavailable in languagesand formatsunderstandable bypatients includinglocal ethnic minoritiesand those who are notfully able.

This may necessitate


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the provision of visualand audio material.

Standard

Level 1*

There should be a checklist in each patient’scase notes addressing whether the patienthas been offered:

• A key worker.• The MDTs information for patients

(written or other formats).• The opportunity of a permanent

record or summary of a consultationat which their treatment options werediscussed.

Note:The checklist may cover other issues. Thisis not subject to assessment.

The assessors shouldsee examples of casenotes showing thechecklist filled in.

Assessment and Care Planning

Standard

Level 1*

The MDT at their regular weekly meetingsshould record the following on at least thenewly referred patients to the team.

• Patient identity.• Diagnosis of underlying disease or

cancer type.• The assessed needs of the patient in

relation to at least the following areas:

(i) Physical.(ii) Psychological.(iii)Social.(iv) Spiritual.(iv) Information needs.(v) Carer(s) identity.

• A reference to the assessed needs of thepatient’s carers.

• A care plan for the patient (and, ifidentified by the MDT as requiring it, aplan for the carers) naming thosemembers of the core and/or extendedteam, or other agencies who are intendedto contribute to the care.

Note:The MDT may choose to discuss patients atother stages in their pathway, and inrelation to other specifically identified areasof need. This is not assessed in this

Examples of a recordof a meeting.

Note:Only exactly what isspecified in the listopposite is necessaryfor evidence. Minutesof discussions overpatients are notrequired.

For assessmentpurposes, patient-specific informationshould be anonymised.


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standard. These issues are addressed underreferral guidelines and clinical guidelines.

Referral Guidelines

Introduction

The guidelines and arrangements identified in standards … to … are essentially about referring apatient to different aspects of the palliative care service and between different parts within theservice. They are therefore classed as the palliative care equivalent of referral guidelines. Thenetwork, for its compliance with standards …. to ….. should produce network-wide guidelinesand the individual MDT, for its compliance with standards ….. to …. should agree to abide by therelevant parts of them.

Standard

Level 1*

Use of Core ServicesThe MDT should agree guidelines with thenetwork for those core palliative careservices which the team covers (out of:inpatient care, day care facilities, outpatientclinic and community-based care). Theguidelines should deal with:

• Patient referral criteria.• Where relevant, admission and discharge

criteria.• Local contact points for each service.

The written guidelinesagreed by the leadclinician of the MDTand the networkpalliative care groupchair.

Note:The contents of theguidelines are notsubject to assessmentsave as per thestandard.

Standard

Level 1*

24-Hour Telephone Advice ServiceThe MDT should agree the networkguidelines for its 24-hour telephone adviceservice with their locally relevantinformation.

The written networkguidelines, agreed bythe lead clinician ofthe MDT and the arealead clinician (ornetwork palliativecare group chairwhere the team andarea lead are the sameindividual).


Standard

Level 1*

0900-1700 Hours Visiting Service The MDT should agree the networkguidelines for its 0900-1700 visiting service,with their locally relevant information.

The written networkguidelines, agreed bythe lead clinician ofthe MDT and the arealead clinician (ornetwork palliativecare group chairwhere the team and


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area lead are the sameindividual).


Standard

Level 1*

MDT Review and DiscussionThe MDT should agree guidelines with thenetwork, stating the criteria which determinethe need for MDT review/discussion of agiven patient at the weekly team meeting.

The written guidelinesagreed by the leadclinician of the MDTand the networkpalliative care groupchair.


Standard.

Level 1*

Care Co-ordinationThe MDT should agree with the network,the arrangements by which the palliativecare of a given patient may be co-ordinatedacross the different core services, localitiesand specialist teams which they may need toaccess.

The arrangements should make reference tothe role of the key worker, identified instandard ….

It is strongly recommended that the referralguidelines and arrangements make referenceto the concept of the patient care pathwayand the key stages of it, at which assessmentfor palliative and supportive care might beneeded:

• Time of diagnosis.• Commencement of the definitive

treatment of the disease.• Completion of the primary treatment

plan.• Disease recurrence or relapse.• The point of recognition of

incurability.

The writtenarrangements agreedby the lead clinicianof the MDT and thenetwork palliativecare group chair.

Note:The contents of thearrangements are notsubject to assessmentsave as per thestandard.


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• End of life care.• Other times requested by the patient.

It is difficult to set a precise standardaround the incorporation of this complexmodel into guidelines. Therefore it is not inthe wording of the standards themselves, inorder to avoid debates between assessorsand those being assessed, over whatconstitutes an acceptable, patient carepathway.

Clinical Guidelines

Introduction

Standards …. and …. are essentially about how to offer palliative and supportive care to a givenpatient in a given situation, rather than being about patient referrals. They are therefore classed asthe palliative care equivalent of clinical guidelines. The network for its compliance withstandards …. to …. should produce network-wide guidelines and the individual MDT, for itscompliance with standards …. To … should agree to abide by them.

Standard

Level 1*

Patient Needs AssessmentThe MDT should agree with the network,guidelines for patient assessment in relationto the following areas of potential need:

• Physical.• Psychological.• Social.• Spiritual.• Carers’ needs.• Information needs.

The writtenguidelines, agreed bythe lead clinician ofthe MDT and thenetwork palliativecare group chair.


Standard

Level 1*

Palliative Care in Specific SituationsThe MDT should agree with the network,guidelines for palliative care of a givenpatient, in at least the following situations:

• Control of specific named symptoms.• Palliative interventions for common

symptom emergencies.• Care of dying patients and their carers.

Note:The MDT may agree additional clinicalguidelines with the network, to those listedabove. This is not subject to assessment.

The writtenguidelines, agreed bythe lead clinician ofthe MDT and thenetwork palliativecare group chair.



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It is strongly recommended that the referralguidelines and arrangements make referenceto the concept of the patient care pathwayand the key stages of it, at which assessmentfor palliative and supportive care might beneeded:

• Time of diagnosis.• Commencement of the definitive

treatment of the disease.• Completion of the primary treatment

plan.• Disease recurrence or relapse.• The point of recognition of

incurability.• End of life care.• Other times requested by the patient.

It is difficult to set a precise standard aroundthe incorporation of this complex model intoguidelines. Therefore it is not in thewording of the standards themselves, inorder to avoid debates between assessorsand those being assessed, over whatconstitutes an acceptable, patient carepathway.

Data Collection

Standard

Level 1

The MDT should agree as an operationalpolicy, to collect the national palliative careminimum dataset (MDS) on each of itspatients.

The MDS, agreed bythe lead clinician ofthe MDT.

Standard

Level 2

The MDT should have started to record theMDS for each patient on proformas or in anelectronically retrievable form.

Assessors shouldexamine examples ofthe recorded data onindividual patients.


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STANDARD &LEVEL


Network Audit

Introduction

For assessment purposes a “network audit project” is an audit project related to palliative carewhich is to be carried out by all specialist palliative care MDTs in the network, each team’sresults being identified.

The minimum progress needed for compliance (since audit is a long and multi-stage process) isthat at least one audit project is agreed with the network palliative care group with sources offunding where necessary, agreed with commissioners or other sources. The MDT should agree toparticipate in the audit projects for its compliance and the network group should produce theprojects with consultation, and with agreed funding for the network for its compliance withstandard …..

Standard

Level 1*

The MDT should agree at least onenetwork audit project with the networkpalliative care group, which is theproject or one of the projects identifiedin standard ….

The named written project withnamed sources of fundingwhere necessary, agreed by thelead clinician of the MDT andthe network palliative caregroup chair.

Note:The nature or appropriatenessof the project is not subject toassessment save as per thestandard. The assessors maywish to comment in theirreport, however.

Standard

Level 2

The MDT should have presented theresults of at least one completednetwork audit project, to a meeting ofthe network palliative care group.

Note:Compliance with standard …automatically confers compliance inaddition, with standards …. and ….

An extract of the minutes ofthe relevant meeting of thenetwork palliative care group.

Topic 9 - Specialist Palliative Care Standards 160304

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Transcript of Topic 9 - Specialist Palliative Care Standards 160304