7a 7 7c Communication tips Breaking Bad New Communication in the last weeks and days of life 22 24-26 26-27 8 Consider The Legal Framework AWI Capacity and Consent Guardianship Power of Attorney Safeguarding vulnerable adults 28-29 29-30 31 31 31 9 Consider Support for Others 32-35 10 10a 10b 10c 10d 10e 10f 10g 10h 10i 10j 10k 10L 10m 10n 10o 10p Consider Physical Care Awareness of Differential Diagnosis and recognising changes in health including deterioration. Pain and Distress. Continence. Epilepsy. Eating and Drinking. Dysphagia. Planning and managing crisis. Medication Maintaining a safe environment. Sleep and night time disturbance. Mobility Skin and tissue viability. Oral Care Orientation/ confusion and memory. Mental Health Eyesight and hearing. 36 36-37 37-38 38 39-42 42-43 43-44 44-45 45 46 47 47-48 49 49-50 50 50-51 11 11a 11b 11c 11d 11e 11f Consider symptom management Pain Breathlessness Weakness/Fatigue Nausea and vomiting Agitation Constipation 51-(36-37) 51-52 52-53 53 53-54 54-55 12 Consider Advance Care Planning 56-58 13 Consider Emotional Response 59-60 13 Consider Spirituality, culture and religion 61
Psychology Physiotherapy Occupational Therapy Speech and Language Therapy Dietician Name Continence Services Address/Telephone/Email Social Work/Care Manager Commissioning Care Organisations Day Services Support Groups including PAMIS Complimentary Therapists Chaplain/Minister/Priest/Ethnic/Cultural Leader. Others such as in Scotland Counselling Services Consider Triggers for Palliative Care Initial Review Review Date Review Date Review Date
Initial Review Added to Care Plan Review Date Review Date Review Date Consider :good assessment should include background information Consider “What Matters To Me” Consider previous exposure to illness, death and dying and bereavement response. Consider individuals social history including they live currently and previous Models of Care. Include who provides support/ model of support/ including level of support and hours funded/, sleepover/wakened night shift/ who else lives here/ family contact and involvement/ other people who are important to individual including friends. Known medical Conditions Previous surgery’s Known or possible Arthritis Mental Health Medication-Concordance, compliance and effectiveness. Covert Medication Allergies Screening History including compliance
Consider using a smaller plate so that the person is not put off with the portion size. Consider flexibility- eat when hungry not essentially at set meal times. Plastic utensils may help if food tastes metallic and when there is a bite reflex. drops mints and gum may help with bitter and metallic tastes. Encourage favourite foods. Have someone else prepare food if required to cut down on odour if necessary. Add spices and sauces/ eat meat with something sweet such as cranberry sauce or apple sauce. Ice or ice lollies may help with taste and feel refreshing when mouth is dry. Good oral care to eating may help . Supplements and Enteral Feeding. Hydration - Intravenous / Subcutaneous fluids Offer oral fluids where appropriate to promote oral hydration. Consider the importance of hydration as appropriate- 2.5 litres of fluid is the recommended amount of fluids we drink in a day. Ensure the person can reach for drink and that they can hold a drink. Dehydration can make people feel very uncomfortable and distressed-thirsty/dizzy/light headed/ mouth dry/sleepy/ confused/ headache. Enteral and Parenteral Feeding-PEG/PEJ. Nutrition-PEG/PEJ. Prescribed advanced medical nutritional supplements. Protocols/Individual guidelines i.e. modified diet including fluids. Continuous review of both nutrition and hydration plan. Identifying Warning Signs -Signs and symptoms of Swallowing Problems (Appendix6). Anorexia and Cachexia prepare ones for gradual change in tolerance of diet. Cachexia is a condition of general ill health, malnutrition, undesired weight loss and loss of muscle mass, physical weakness, often associated with cancer. The loss of body mass cannot be
Aids such as pressure airflow mattress/ pressure cushions/appropriate seating/ pillows/posture rolls and wedges/leg and foot protectors and supports. Risk Assessment i.e. Waterlow Score, Pressure Area Risk Assessment Chart; Braden Risk Assessment Tool; Preliminary Pressure Ulcer Risk Assessment (PPURA); moving and handling. Tissue Viability contact-Who and Consider staff training Issues Initial Review to Care Plan Review Date Review Date Review Date Oral Care Assessment and Care planning Helps maintain, comfort, self- esteem and dignity. Supports and promotes communication Supports and promotes nutritional intake and hydration. Treatments such as chemotherapy, radiotherapy, analgesics such as opioids, diuretics and anticholinergic’s can cause uncomfortable dryness leading to sore mouths. Some individuals may be prescribed medication for excessive salivation this should be reviewed and amended as appropriate. Maintain on a bases regular mouth care (4 times a day).Ensure you have the tools and equipment available to this such as a soft toothbrush, lip balm etc. Support, advice and training from District Nurse if necessary. Check for changes and put interventions in place quickly to prevent deterioration.
East Ayrshire Community Learning Disability Team Nicky Jenkins CLDT co-ordinator Area Centre KA3 1NQ Telephone: 01563 578567 North Ayrshire Community Learning Disability Team Marion Gilchrist CLDT co-ordinator KA12 8SS Telephone: 322172 NHS Greater Glasgow and Learning Disability Liaison Team Nicola Robinson pciladmin.generic@ggc.scot.nhs.uk CHP – North East Sector Community Learning Disabilities Team Raymond Doonan Former Trust HQ Telephone: 0141 201 4109 CHP – Sector Community Learning Disabilities Team Marie MacDonald Glenkirk Centre G15 6PX Telephone: 0141 232 1340 CHP – Sector Community Mandy McLaughlin Eugene Kelly 10 Ardencraig Place Castlemilk
Learning Disabilities Team Lorraine Millington G45 9US Telephone: 0141 276 4900 CHP Community Learning Disabilities Team Leslie Buchannan Kirkintilloch Health Care Centre Kirkintilloch G66 3BF Telephone: 0141 355 2200 CHP Community Learning Disabilities Team Julie Fitzpatrick Learning Disabilities Services Beardmore Business Centre Dalmuir G81 4HA Telephone: 0141 562 2333 CHCP Community Learning Disabilities Team Sharon McGhee Barrhead Centre Barrhead G78 1AA Telephone: 0141 577 3967
Renfrewshire CHCP Community Learning Disabilities Team Ann.Fitzsimmons Renfrewshire Health & Social Care Centre 2nd Floor Renfrew PA4 8RU Telephone: 0141 207 7800 Inverclyde CHP Community Learning Disabilities Team Stewart McCorkindale Cathcart Centre PA15 1BQ Telephone: 499 053 / 054 NHS Grampian LD Team Sue Grassick AB24 5AU Telephone: 558319 Aberdeenshire Central LD Team Sara Cook Gate House Inverurie AB51 3UL Telephone: 01467 672780 Aberdeenshire LD Team Sara Cook Units 12 & 13 The Green Portlethan AB12 4UN
Telephone: 01224 785070 Aberdeenshire North LD Team Karen Donald 1, Macduff AB44 1US Telephone: 01261 813555 Moray LD Team Jane Sheapherd Highfield House Terrace IV30 1NE Telephone: 01343 562116 NHS Highland Inverness Community LD nurses Community Learning Disability Nursing Service Corbett Centre Coronation Road IV3 8AD Telephone: 01463 712342 Nairn, Ardersier, Badenoch and Strathspey Community LD Nurses Grant Community Learning Disability Nursing Service Town and Nairn IV12 5EE Telephone: 01667 422814
Telephone: 0131 537 4261 LD Team Dunpender Haddington EH41 3BU Telephone: 0131 536 8542 East LD Team Community Treatment Centre EH6 5JA Telephone: 0131 536 6257 LD Team Bonnyrigg Health Centre Quarry Head Bonnyrigg EH19 2ET Telephone: 0131 537 9924 NHS Orkney All Age Learning Disability Service Tom McGuire Service Manager Orkney Health and Care Council Offices KW15 1NY Telephone: 01856 873535 NHS Dumfries and Galloway and Galloway LD Service Shona Young Telephone: 01387 246914 (Ext: 34914)
NHS Fife LD Team Moyles (Referral KY11 4UW Telephone: 01383 565230 Palliative Care Directory Area Department Team leader Contact Details Ayrshire and Arran - Ayr Ayrshire Hospice Aileen Anderson (Nursing and Hospice Services) KA7 2TG 01292 269200
Ayrshrie and Arran - Ayr Hospital Palliative Care Service – Dr Kathleen Sherry (Consultant in Palliative Medicine) KA6 6DZ 01292 610555 Borders Borders Macmillan Centre Elaine Peace (Macmillan nurse consultant – Cancer and Palliative Care) Borders Macmillan Centre TD6 9BS 01896 826888 Dumfries and Galloway – Annan Macmillan Services Macmillan Services Annan Clinic Annan DG12 5AG 01461 205218 Dumfries and Galloway – Dumfries Specialist Palliative Care Service Maureen MacRae (Manager) Specialist Palliative Care Service Alexandra Unit Dumfries and Royal Infirmary DG1 4AP 01387 241347 Macmillan Clinical Nurse Specialist Moira Dale (CNS) Macmillan Centre Dumfries and Royal Infirmary DG1 4AP
01387 241981/241931 moira.dale@nhs.net Dumfries and Galloway – Newton Stewart Macmillan Service Macmillan Service The Health Centre Creebridge Stewart DG8 6NR 402587 Fife – Cupar Hospice Unit Hospice Unit Bank Street Cupar KY15 4JG 658451 Fife – Hospice Ward (Ward 16) Dr Sheena Scragg (Consultant in Palliative Medicine) Linda Sprinks (Charge Nurse) KY12 0SU 627016 Fife – Kirkcaldy Victoria Hospice Dr Fran Stretton (Consultant in Palliative Medicine) Heather Spence (Charge Nurse) Victoria Hospice Kirkcaldy KY2 5AH 648072 Palliative Care Service Dr Sheena Scragg Palliative Care Services
Dr Preston Dr Fran Stretton (Consultants) Cedar house Kirkcaldy KY1 2LF 01592 648004 Fife – St Andrew’s Hospice Unit Dr Clive Preston (Consultant in palliative medicine) Nolan (Charge Nurse) Hospice Unit Walk St Andrew’s KY16 9LG 01334 468671 Forth – Denny Strathcarron Hospice McKie (Director) Strathcarron Hospice Denny Stirlingshire FK6 5HJ 826222 Forth – Falkirk Palliative Care Team at Royal Infirmary Palliative Care Team Royal Infirmary Livilands FK8 2AU 01786 434454 Forth – Stirling Palliative Care Team Dr Downs (Consultant in Palliative Care) Evelyn Paterson (CNS) Palliative Care Team Infirmary Livilands FK8 2AU 01786 434454
Grampian – Aberdeen Roxburgh House Dr Tim Morgan (Head of Service) Roxburgh House Department of Palliative Medicine Cornhill Site AB25 2ZH 557057 NHS Grampian Community Macmillan Nursing Service Margaret McLellan Community Macmillan Nursing Roxburgh House Cornhill Site AB25 2ZH 01224 557101 Hospital Specialist Palliative Care Team Dr Tim Morgan (Head of Services) Flora O’Dea Donna Ewan (CNSs) Hospital Specialist Palliative Care Team Room 15, Human Resources Royal Infirmary Foresterhill AB25 2ZN 01224 554001 Grampian – Macmillan Service Mathieson Macmillan Service The Health Centre AB45 1HY 01261 819182 Grampian – The Oaks Palliative Care Day Centre The Oaks Palliative Care Day Centre
Morrayshire IV30 6UN 01343 555104 Grampian – Fraserburgh Macmillan Service Moira Gordon Macmillan Service Fraserburgh AB43 9NH 01346 585274 Grampian – Peterhead Community Macmillan Nurse Community Macmillan Nurse Peterhead Health Centre Links Terrace Peterhead AB42 6XA 4825668 Highland – Macmillan Service Macmillan Service Health Centre High Street Rothesay PA20 9JL 01700 501507 Highland – Campbeltown Palliative Care Service Palliative Care Service Campbeltown PA26 6LE 01586 555822
Highland – Dunoon Cowal Hospice Julie McNaughton (Manager) Cowal Hospice Dunoon Argyll PA23 7Rl 01369 707732 Highland – Fort William Macmillan Service Kathryn McCall (CNS Team Leader) Macmillan Service PH33 6BS 01397 702481 Highland – Golspie Macmillan Nurse Marion Mackay Macmillan Nurse Golspie East Sutherland KW10 6ST 01408 664063 Highland – Inverness Hospice Maria McGill (Chief Executive) Dr Stephen Hutchison (Medical Director) McCormack (Educational/Clinical services Director) Hospice House 1 Bishop’s Road IV3 5SB 01463 243132 Children’s Hospice Association Scotland – Rachel House at Home Team Children’s Hospice Association Scotland – Rachel House at Home Team c/o Hospice
Highland – North and West Sutherland Macmillan Nursing Service Macmillan Nursing Service Lairg IV27 4DD 01549 402556 Highland – Oban The Oban Hospice King (Manager/Charge Nurse) The Oban Hospice Oban Argyll PA34 4HH 567500 Macmillan Home Care Nurse Lucy Heycock Macmillan Home Care Nurse Oban Argyll PA34 4HH 01631 567500 Highland – Ross Shire Macmillan Maryann More Macmillan Nurse Ross Lodge Ferry Road Dingwall Ross shire IV15 9QF 01349 868 771 Highland – Skye and Lochalsh Macmillan Service Barbara MacDonald Nancy MacAskill Macmillan Service South Wester Ross
EH10 7DR 0131 470 2201 Care: Milestone Jonathan Creel (Care Services Manager) Liz Marr (Care Team Manager) Care: Milestone House EH14 1EB 0131 441 6989 Palliative Care Team Charter Palliative Care Team Directorate of Clinical Oncology EH4 2XU 0131 537 2243 Palliative Care Service Dr Kirsty Boyd (Consultant in Palliative Medicine) Debbie Crawford Hughes (CNSs) Palliative Care Service c/o Royal Infirmary of 51 Little Old Lothian EH16 4RS 0131 242 1993 Lothian – Haddington Macmillan Nurses Macmillan Nurses Community Nursing Office Haddington EH14 3PF 0131 536 8332
Lothian – Livingston West Lothian Specialist Palliative Care Service Dr Juliet Spiller (consultant in palliative medicine) West Lothian Specialist Palliative Care Service Macmillan Centre Howden EH54 6PP Orkney Orkney Macmillan House Orkney Macmillan House New Orkney KW15 1BH 01856 888249 Shetland Macmillan Nursing Service Macmillan Nursing Service Lerwick Shetland ZE1 0TB 01595 743347 Tayside – Brechin Macmillan Centre Dr Martin Leiper (Consultant in palliative medicine) Ann Petrie (Clinical coordinator) Anne Pender (Charge Nurse) Macmillan Centre Brechin Angus DD9 7QA 01356 665014 Tayside – Roxburghe House Anne Robb (Service Manager) Roxburghe House
DD2 1SP 01382 423000 Palliative Care Team Helen Dryden (Team Leader/CNS) Palliative Care Team and Ninewells DD1 9SY 632478 Tayside – Forfar Lippen Care – Strathmore Hospice Hamill (Ward Manager) Elizabeth Forsyth (Manager Lippen Care) Lippen Care – Strathmore Hospice Whitehills Centre Station road Forfar DD8 3DY 01307 475256 Tayside – Kinross Children’s Hospice Association Scotland – Rachel House Marian Keogh (Chief Executive) Dr Patrick Carragher (Medical Director) Libby Gold (Head of Care) Children’s Hospice Association Scotland – Rachel House Avenue Road Kinross KY13 8FX 01577 865777 Tayside – Macmillan House Dr Allison Morrison (consultant in palliative medicine) Ann Gourlay (Palliative services manager) Macmillan House PH2 7HQ
Ceartas Advocacy 7 McGregor Kirkintilloch G66 1XF Telephone: 0141 775 0433 e-mail: Carers Link (for carers) Milngavie Enterprise Centre Milngavie G62 8PH Telephone: 0141 955 2131 e-mail: Lomond Advocacy Services Dumbarton G82 1RH Telephone: 01389 726 543 e-mail: Inverclyde Inverclyde Advocacy Service PA15 1 YF Telephone: 01475 730 797 e-mail: