Recommended Core Education Standards for Care and Support for the Dying Person in the Last Days and Hours of Life

Transcription

1 Recommended Core Education Standards for Care and Support for the Dying Person in the Last Days and Hours of Life This Document is relevant for health and social care professionals who have potential contact with the dying person, their family and those close to them Date of issue: October 2014 Date for review: 31 st October 2015 Status: Version 1.0 Prepared by: This is a consensus document developed by the Greater Manchester, Lancashire and South Cumbria Strategic Clinical Network s Palliative and End of Life Care Education and Training Group. 1

2 Contents Foreword and Purpose Page 3 1. Introduction Page 4 2. How to use this document Page 5 3. Objectives 3.1 Group C Staff Page Group B Staff Page Group A staff Page Implementation and support for education and training Page Assessing Individual Professional Competences Page Trainers and Educators in Palliative and End of Life Care Page Appendix 7.1 Potential E-ELCA Modules Page Local Template to Map Current Training Page Resources for Professionals Page References & Acknowledgements Page 29 2

3 Foreword Health and care staff must demonstrate kindness as well as the skills, confidence and the application of knowledge in the care of those in the last days and hours of life. This will facilitate a culture of care that is compassionate, recognises the individual needs of the dying person and their families, as well as being open and transparent by respecting the duty of candour to which the individual is entitled. Achieving this requires: commitment from staff Employers and commissioners to make learning time and resources available Employers to undertake regular staff performance reviews: 1 The Leadership Alliance for Care of dying people sets out an approach to caring for dying people that health and care organisations and staff caring for dying people in England should adopt in future. The approach should be applied irrespective of the place in which someone is dying: hospital, hospice, own or other home and during transfers between different settings. Five Priorities for Care are outlined in this approach. ( The Priorities for Care for when it is thought that a person may die within the next few days or hours. 1 This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person s needs and wishes, and these are regularly reviewed and decisions revised accordingly. 2 Sensitive communication takes place between staff and the dying person, and those identified as important to them. 3 The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants. 4 The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. 5 An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion. Purpose of SCN Recommended Standards Document One purpose of this document is to provide a basis for commissioners and providers within localities to continue and further develop mandatory education and training to support care in the last days and hours of life It is also hoped that this document can be used by managers and individual professionals to reflect on an individual s knowledge, competencies and practice, within their role in delivering the priorities for care in the last days of life. This reflection should include the skills and competencies that professionals already possess as well as areas for development. These discussions could then be included within an individual s wider professional development reviews. Although this document outlines core areas of knowledge for Group A,B and C Staff, it is NOT expected that every professional, within their own role, would need all of these core areas of knowledge as these areas of knowledge are role and profession dependent. 3

4 Introduction The principles of palliative and end of life care apply from a much earlier point in a Person s life-limiting illness. Advance care planning, symptom control, rehabilitation to maximise social participation, and emotional and spiritual support are all important in helping the individual to live well until they die. This document provides guidance specifically for care when a person is imminently dying, i.e. death is expected within a few hours or very few days. It is important to ensure that all professionals involved in the care and support of the dying person in the last days and hours of life are: Safe Effective Competent Confident Delivering a high standard of care Appraised annually These recommended standards promote consistency of education and training across the Strategic Clinical Network and the competencies that professionals require for their role in clinical practice. The core areas of knowledge headings are drawn from the Strategic Clinical Network Principles of Care and Support for the Dying Patient (2013). All staff must be able to provide evidence to show they have a level of competency that will be appropriate to their role, linked to individual professional Personal Development Plans (PDP), as well as Continual Professional Development (CPD) for medical staff. Standards and competences also need to be mapped to local models of care, as roles and functions may differ across organisations and settings to reflect flexible and integrated care of the dying person and their families. All health and Social care professionals should address these standards in line with organisations policies and protocols. Education and training for all professionals delivering care and support of the dying person in the last days and hours of life should involve: 3 Mandatory training at induction : Annual updates that should cover any recommended changes to practice and the most up to date policies and guidelines. The End of Life Care Strategy (2008), 4 stipulates that: ensuring that health and social care staff at all levels have the necessary knowledge, skills and attitudes related to care for the dying will be critical to the success of improving end of life care. For this to happen, end of life care needs to be embedded in training curricula at all levels and for all staff groups. End of life care should be included in induction programmes, in continuing professional development and in appraisal systems. 3 4

5 How to use this document The document will begin by outlining Group C staff competencies. Group B staff competencies will be inclusive of competencies outlined in Group C and Group A staff competencies will be outlined and inclusive of the competencies outlined in group A and group B Group Definitions and Minimum Skill and Knowledge Levels, adapted from: Common Core Competencies Skills for Health Matched to Skills for Health Career Framework GROUP DEFINITION GROUP C: staff working within other services who are infrequently involved with the care and support to the dying person and those closest to them in the last days and hours of life GROUP B: staff who frequently deal with the care and support for the dying person and those closest to them in the last days and hours of life as part of their role GROUP A: specialist palliative care staff, working entirely focused on the care and support to the dying person and those closest to them in the last days and hours of life. MINIMUM SKILL AND KNOWLEDGE LEVEL Good basic grounding in the principles and competences; for the care and support for the dying person and those closest to them in the last days and hours of life, alongside knowledge of where to seek expert advice or refer on to Need to be enabled to develop or apply existing skills and knowledge to the principles and competences for the care and support of the dying person and those closest to them in the last days and hours of life. May require additional specialist training Highest levels, through specialist training. To include all of common core competences for the care and support for the dying person and those closest to them in the last days and hours of life. Examples of group staff (guide) Ancillary staff, ward clerks, reception staff, porters, transport staff, nurses, AHP, HCA Skills for Health career framework level 1-3 GPs, district nurse, consultants medics, ward nurses, Hospice nurses, HCA, AHP, domically staff, social care, nursing home staff, dementia workers, specialist other, Chaplin s, Ambulance staff Skills for Health career framework level 4-6 Consultants in Palliative Medicine, Specialist Palliative care doctors, nurses, social workers, AHP, Skills for Health career framework level 7-9 Reminder about the law on capacity for all groups of professionals Staff must operate within the legal framework provided by the Mental Capacity Act 2005 (MCA) and its code of Practice. The Act makes clear who can take decisions in which situations, and how they should go about this. Anyone who works with or cares for an adult who lacks capacity must comply with the MCA when making decisions or acting for that person. The Act sets out five statutory principles that must guide decisions, including requirements that staff ensure that those who may lack capacity to decide are empowered to make as many decisions for themselves as possible and that any decision made, or action taken, on their behalf is made in their best interests. If an Advance Decision to Refuse Treatment (ADRT) exists and is valid and applicable (within the terms of the act and code), it must be followed. Individuals who have been nominated by the dying person to be involved in decisions and those who hold Lasting Powers of attorney (LPA) relating to health and welfare issues must be involved in decisions. Those who hold a registered LPA for health and welfare may have legal authority under the terms of the LPA to make the decision on behalf of the dying person. 1 5

6 Group C staff GROUP C: staff working within other services who are infrequently involved with the care and support to the dying person and those closest to them in the last days and hours of life Good basic grounding in the principles and competences; for the care and support for the dying person and those closest to them in the last days and hours of life, and where to seek expert advice or refer on to Core Areas of Knowledge Target Group Learning Objectives: All Staff must understand the importance of working within the parameters of their role according to policies and guidelines. Staff themselves has responsibilities to ensure that they have the necessary skills to do their jobs and to keep those skills up-to date. Clinical Review and Diagnosing Last Days of Life Group C Recognise signs of the last days of life and informing other key professionals involved in the person s care. Be aware of benefits and burdens of investigations and other observations. Be aware of the clinical levels of intervention/ ceilings of care. Report any reversible causes of deterioration to key professionals involved in the person s care. Be aware when to refer onto specialist Palliative Care and other Teams. Discuss and Agree Care Plan Group C Listen and respond sensitively to questions regarding the plan of care, acknowledging the limitations of knowledge and referring onto an appropriate member of the care team when necessary. Be aware of the individual plan of care and support for the dying person in the last days and hours of life. Be aware of Advance Care Planning (ACP) and the Mental Capacity Act (2005) and its code of practice. Be aware of the wellbeing of families, clearly explaining the facilities available in the environment. Communicate to all Involved Group C Consider the needs of dying people who cannot communicate easily, either because their first language is not English or because they have a sensory, physical or mental impairment, will require additional time and assistance, and these staff must know how to seek specialist help, including an interpreter, or special aids if required. Listen, acknowledge concerns and provide information when able to do so, to the dying person, their family or those closest to them regarding their concerns related to the end of life. Check understanding of information and explanations given. Proactively provide information in simple, appropriate, straight forward language without using euphemisms. 6

7 Document Individual Plan of Care and Support for the Dying Person in the Last Days and Hours of Life Conversations Care Mouth Care Hygiene Needs Skin Integrity Support oral food and hydration Symptoms Family Support Spiritual Care Acknowledge and respect the wishes of the dying person, their family or those closest to them. Establish who the dying person wishes information to be shared with regarding their condition. Ensure the person understands what information is being shared and how this will be used and shared, protecting confidential information as a legal duty. Respond in a flexible and sensitive manner to the emotional needs of the dying person, their family or those closest to them. Acknowledge and refer appropriately with regards to the wishes of the dying person in relation to organ and tissue donation. Refer appropriately to other health and social care professionals and agencies. Group C Be aware of the importance of documenting all aspects of care. Document and communicate conversations with the dying person In respect of their preferences. Comply with the Mental Capacity Act (2005) and its code of practice, including: Lasting Powers of Attorney (LPA): Health and Welfare Property and Financial Affairs Advanced Decision to Refuse Treatment (ADRT) Identify and document any significant changes in the dying person s condition reporting this to the relevant health and social care providers. Document and report any emotional distress of the dying person or those important to them. Group C Be aware of potential physical symptoms and how to recognise they are present: Pain, Nausea/ Vomiting, Breathlessness, Noisy Breathing, Agitation, Confusion, Dry mouth, Constipation and urinary retention. Be aware of potential physiological symptoms and how to recognise they are present: anxieties worries and concerns. Seek senior and/or specialist support in any aspect of holistic assessment or delivering care and treatment when this is beyond their competence, including clinical, physical, psychological, emotional, social, spiritual and /or religious support. Document and Inform other key professionals involved in person s care on recognition of symptoms. Observe for potential side effects of medications and report concerns. Respond to anxieties, worries and concerns of the person. Respond to the cultural spiritual and / or religious needs of dying person and those important to them. Care for a person with oxygen. Care for a person with a urinary catheter. Understand the principles of use for a McKinley T34 (or other) Syringe Pump. Ensure syringe pump recording chart & care plans are completed as per policy. Support the dying person to eat and drink as long as they wish to do so and there is no serious risk of harm. Administer mouth care - Considering oral moisture gels/ lip salves. Competently manoeuvre the dying person according to the manual handling assessment. Support hygiene needs including hair care and shaving. 7

8 Promote the Maintenance of Privacy & Dignity. Support the care plan to manage skin integrity, considering the need for pressure relieving and other equipment needs. Assessing and reviewing the needs of the family or those that are important to the dying person. Re-evaluate Group C Understand the need and process for regular review, and act on any changes in care. Recognise changes in condition or new symptoms occurring and communicate to relevant staff. Carry out effective reviews as directed in the Individual Plan of Care and Support for the Dying Person in the Last Days and Hours of Life and to escalate when senior review is needed earlier than planned. Ensure timely communication and sharing of information between the health and social care team caring for the dying person and those important to them. Support communication of a review with the dying person and those important to them in the parameters of the role or ensure information requests are acted upon. Monitor symptom management and be able to use prescribing guidance safely. Understand the need and appropriate time to refer to specialist services. Care After Death Group C Work in accordance with care of the body after death policies. Support families and friends of the deceased. First steps of bereavement care. 8

9 Group B staff GROUP B: staff who frequently deal with the care and support for the dying person and those closest to them in the last days and hours of life as part of their role Need to be enabled to develop or apply existing skills and knowledge to the principles and competences for the care and support of the dying person and those closest to them in the last days and hours of life. May require additional specialist training **Inclusive of Group C competencies** Core areas of Knowledge Target Group Learning Objectives All Staff must understand the importance of working within the parameters of their role according to policies and guidelines. Clinical Review and Diagnosing Last Days of Life Discuss and Agree Care Plan Staff themselves has responsibilities to ensure that they have the necessary skills to do their jobs and to keep those skills up-to date. Group B Recognise and manage the reversible causes of deterioration. Act upon the recognition or the signs that a person is clinically unstable and may not recover. Involve the dying person and those important to them as much as possible in decisions about the plan of care.assess mental capacity for each decision needing to be made. Review the place of care in line with the person s wishes and or best interest. Review the benefits and burdens of investigations and other observations. Contribute to clinical decision making to identify the clinical levels of intervention/ ceilings of care including clinical decisions around DNACPR Request/ prescribe anticipatory medications for potential specific symptoms. Effectively communicate senior clinical handover from In-hours to Out of Hours, regarding the Individual Plan of Care and Support for the Dying Person in the Last Days and Hours of Life Be aware of the management for Implantable Cardiac Defibrillators (ICD) and possible deactivation (ICD Deactivation Policy available on request from the Strategic Clinical Network). Communicate the individualised plan of care and support for the dying person to other key professionals involved in person s care. Group B Sensitively explore questions from the dying person, their family or those closest to them, regarding the plan of care, including: Current clinical situation/ dying persons condition Agreeing aims and expectations of care being provided Levels of intervention/ treatment limitations including DNACPR Recognising clinical uncertainties re: care and interventions Nutrition and Hydration Symptoms and medication required Seek a second opinion if there is continuing difference in opinion about the treatment of care or if additional reassurance would be helpful. Initiate, review and re-evaluate the individual plan of care and support for the 9

10 dying person in the last days and hours of life. Proactive Advance Care Plan (ACP) within the MCA (2005) and its code of practice. To have knowledge, comply and provide leadership with the Mental Capacity Act (2005) and its code of practice, including: Lasting Powers of Attorney (LPA): Health and Welfare Property and Financial Affairs Advanced Decision to Refuse Treatment (ADRT) Link to Best Interests at End of Life (May 2008) Communicate to all Involved Group B Act as key worker for the dying person and their family. Confidently establish where the dying person wishes to be cared for in the last days of life directly with the dying person or within the best interest framework. Actively include the dying person and those and those important to them in agreeing a care plan making clear if they are being informed about, consulted about, involved in or taking particular decisions about treatment and care. Facilitate a rapid discharge/transfer from inpatient care if it is the wish of the dying person. Plan for rapid discharge/transfer between care setting in an emergency situation. Manage the potential risks caused by multiple sets of documentation. Actively communicate the care needs and wishes of the dying person to other health and social care teams involved. Actively seek the wishes and act upon the dying persons wishes regarding organ/ tissue donation. Review any Advance Care Plan/Advance Decision to Refuse Treatment (ADRT) documentation in line with the MCA (2005) and its code of practice.. Senior doctors, Band 7 staff and above Other professionals up to Band 6 and equivalent Develop and maintain communication with people about difficult and complex matters or situations related to end of life care. Confidently recognise the emotional needs of the dying person and those important to them. Confidently respond in a flexible and sensitive manner to the emotional needs of the dying person and those important to them. Confidently negotiate with the dying person and those important to them in relation to their needs and care. Sensitively discuss key information with the dying person and those important to them. Resolve communication problems raised by the dying person and those important to them.. Develop and maintain communication with people about difficult matters or situations related to end of life care. Confidently recognise the emotional needs of the dying person and those important to them. Confidently respond in a flexible and sensitive manner to the emotional needs of the dying person and those important to them. Confidently negotiate with the dying person and those important to them in relation to their needs and care. Sensitively discuss key information with the dying person and those important to them. 10

11 . Document Individual Plan of Care and Support for the Dying Person in the Last Days and Hours of Life Conversations Care Mouth Care Hygiene Needs Skin Integrity Support oral food and hydration Symptoms Family Support Spiritual Care HCAs and patientfacing support staff Listen, acknowledge and respond to individuals, their families and friends about their concerns related to the end of life and provide information and support. Confidently recognise the emotional needs of the dying person and those important to them. Confidently respond in a flexible and sensitive manner to the emotional needs of the dying person and those important to them. Signpost appropriately to other health and social care professionals. Group B Comply with professional guidelines of documentation. Anticipate and recognise the changes within the dying person s condition. Formulate a plan of care following holistic assessment of the patient s needs, where possible in collaboration with the dying person and those important to them to identify their hopes and goals. Document and report any emotional distress of the dying person and those important to them. Initiate and manage conversations with the dying person regarding their preferences at the end of life, utilising Advanced Care Planning (ACP) in compliance with the MCA (2005) and its code of practice. Clarity in verbal and written handovers between professionals, and across shifts/ duty periods and settings (e.g. community and hospital care) to ensure consistent care and communication with the person and those important to them. Group B Assess and manage the physical, psychological, social and spiritual needs of the dying person, their family and those closest to them. Assess, manage and document potential physical symptoms including: Pain, Nausea/ Vomiting, Breathlessness, Noisy Breathing, Agitation, Confusion, Dry mouth, Constipation and urinary retention. Initiate, prescribe or administer (as appropriate to role) anticipatory prescribing of medications for specific potential symptoms. Review of existing medications, current symptoms and medication/treatment options. Observe and manage potential side effects of medication. Prescribe and administer by (as appropriate to role) the appropriate route of medications if swallowing is difficult and consider subcutaneous injections and use of McKinley T34 Syringe Pump (or other). Specify symptom, drug, dose and dying person s response to medication. Competently use and monitor McKinley T34 syringe pump (or other) and understand the decision making process when commencing and communicate this with the dying person and those important to them. Maintain quality personal care i.e. Management and insertion of urinary catheter assess and manage oxygen therapy, ensure hygiene needs including hair care, oral care and shaving are met. Assess, manage and review the cultural needs of dying person and those important to them, considering any specific needs before death or at death. Promote the maintenance of privacy & dignity. Understand the challenges and ethical issues regarding nutrition & hydration the importance of keeping the dying person and those important to them at the centre of the decision making process. Assess and manage nutrition and hydration. Consider clinically assisted nutrition/ hydration (including safety risks versus benefits). 11

12 Record clinical decisions re: stopping/ starting and continuing clinically assisted nutrition and hydration. Assess and review the needs of the family (communication booklet or equivalent). Enhance the environment appropriate to the dying persons wish and those important to them i.e. side room, bed downstairs. Re-evaluate Group B Review the dying person and the needs of those important to them regularly. Identify changing needs and recognising when active treatment should be considered. Ensure a senior clinician is included or informed of the review of the dying person and those important to them. Proactively communicate any change in care plan including the rational with the dying person, their family or those important to them and the health and social care team. Recognise the need and timing of referral to specialist services. Evaluate the effectiveness of symptom management. Competently respond to changing medication using local prescribing guidance and the safe practice use of McKinley T34 Syringe Pump (or other). Care After Death Group B Sensitively inform carers that a death has occurred. Provide Level one psychological support to the bereaved. Care of the body after death, respecting any known cultural and religious belief. Recognise the cultural or religious needs of families in bereavement. Manage the immediate practical issues after death. Provide opportunity for families to participate in the care of the body after death as they wish. Identify, support and refer appropriately people at risk in bereavement. Give information in a sensitive manner to families about practical issues following death. Understand what happens after a death, the role other agencies play and be able to signpost if support is needed. Recognise when personal experiences of death and dying, stress and bias may affect own capacity to deal with the bereaved. Verify an expected death in line with organisational policies/procedures. Approach bereaved relatives following death regarding a person who wishes to donate tissue or organs when appropriate. Be aware of the legislation regarding issues of consent to tissue donation. Demonstrate an understanding of the process of tissue donation after death as appropriate. Demonstrate understanding of the impact of loss and grief, including how to support individuals who are bereaved. 12

13 Group A staff GROUP A: specialist palliative care staff, work entirely focused on the care and support to the dying person and those closest to them in the last days and hours of life. Highest levels, through specialist training. To include all of common core competences for the care and support for the dying person and those closest to them in the last days and hours of life. **Inclusive of Group B and C competencies** Core areas of Knowledge Target Group Learning Objectives All Staff must understand the importance of working within the parameters of their role according to policies and guidelines. Staff themselves has responsibilities to ensure that they have the necessary skills to do their jobs and to keep those skills up-to date. Clinical Review and Diagnosing Last Days of Life Discuss and Agree Care Plan Group A Makes provisions for uncertainty about whether someone is dying and supports professionals in managing that uncertainty and communicate it with the dying person and those who are important to them. Provide specialist support and leadership the team discussions and decisionmaking re: prognosis of a few days or hours for this person addressing: Underlying diagnosis and other clinical conditions, Compliance with Mental Capacity Act (MCA) 2005 and its code of practice, Reversible causes of deterioration have been treated effectively or excluded in accordance with the person s wishes or best interests if it is established they lack capacity. Provide specialist support and leadership to demonstrate clear decision making in the review of benefits and burdens of investigations and other observations. Provide specialist support to clinical teams identifying the clinical levels of intervention/ ceilings of care. Assess and manage palliative care emergencies. Understand the principles of assessing Mental Capacity in accordance to MCA (2005) and its code of practice. Group A Consider which decisions need to be made on the spot to ensure a person s safety and comfort and which can and must wait for a review of the persons condition by the senior doctor who has responsibility for the persons treatment and care. Provide specialist support to the care team, the dying person, their family or those closest to them in exploring questions regarding the plan of care including: Current clinical situation/ dying persons condition, Agreeing aims and expectations of care being provided, Levels of intervention/ treatment limitations, Recognising clinical uncertainties, Issues of supporting nutrition and hydration, 13

14 Symptoms and medication required. Provide specialist support to initiate, review and re-evaluate the individual plan of care and support for the dying person in the last days and hours of life taking into account the views of the wider multi professional team. Provide leadership to manage complex situations within the MCA (2005) and its code of practice. Manage complex situations to negotiate the plan of care with the dying person or in the best interest of the dying person. Discuss plans relating to ongoing provision of care that meets the persons need. Communicate to all Involved Document EoL Care Plan Conversations Care Mouth Care Hygiene Needs Skin Integrity Support oral food and hydration Symptoms Family Support Spiritual Care Group A Actively provide open and honest communication and provide specialist support regarding the care needs and wishes of the dying person to other health and social care teams involved. Role model sensitive communication to actively seek the wishes of the dying person re: organ/ tissue donation. Provide specialist support to review any Advance Care Plan/Advance Decision to Refuse Treatment (ADRT) documentation working in line with the Mental Capacity Act (MCA) 2005 and its code of practice. Develop and maintain communication with people about difficult and complex matters or situations related to end of life care. Knowledge to communicate with children or signpost to resources for children experiencing the death of someone close to them. Confidently negotiate with the dying person and those important to them in relation to their needs and care. Sensitively discuss key information with the dying person, and those important to them. Identify and address communication problems raised by the dying person and those important to them. Group A Apply clinical judgement to be able to formulate a plan of care following holistic assessment of the dying person s needs, where possible in collaboration with the dying person and those important to them to identify their hopes and goals. Assess, manage and review signs of common palliative care emergencies. Initiate and manage complex conversations with the dying person regarding their preferences at the end of life, utilising Advance Care Planning (ACP) in compliance with the MCA (2005) and its code of practice. Ensure decisions re ACP are documented and shared with appropriate health and social care providers involved in the care and support of the dying person, their family or those closest to them. Anticipate and recognise the changes within the dying person s condition. Group A Assess and manage complex physical, psychological, social and spiritual needs of the dying person, their family and those important to them. Assess and manage complex physical symptoms including: pain, nausea/ vomiting, breathlessness, noisy breathing, agitation, confusion, dry mouth, constipation and urinary retention. Lead the review of existing medications, current symptoms and medication/treatment options. Lead the review of medications to prescribe or stop. Document and communicate reasoning. Understand the use of anticipatory medication and communicate this with the dying person and their family. 14

15 Understand role of Specialist Palliative Care (SPC) in relation to acute oncology. Competent, knowledgeable and credible resource able to deliver training to all groups of staff on the use of McKinley T34 Syringe Pump (or other). Role model high quality care provision. Provide peer support to colleagues. Explore the challenges and ethical issues regarding nutrition & hydration and to be able to support generalist colleagues in appropriate decision making whilst keeping the dying person and their families at the centre of the decision making process. Manage complex nutrition and hydration care and support the dying people s family in relation to this. Role model decision making within the MCA (2005) and its code of practice and best interest decision guidance to make decisions if a person lacks capacity regarding nutrition and hydration. Promote the dying persons psychological, spiritual and religious needs and those of their family and those closest to them. Promote the care for the individual cultural needs of the dying person, considering any specific needs before death or at death. Act as Key Worker for the dying person and their family or those close to them. Re-evaluate Group A Ensure regular review of the dying person and those important to them and respond to the review to continue or amend the plan of care. Recognise the need and timing of referral to other specialist services. Support the care delivery and management of symptoms by junior group A, B and C staff and provide care when appropriate Provide peer support and education for groups B & C staff when required. Provide Specialist review to support the care delivery and management of symptoms and holistic needs when needed. Care After Death Group A Undertake a bereavement risk assessment. Provide psychological support to the bereaved with complex grief. Provide informal clinical supervision and support to group B and C staff if needed. 15

16 Implementation and Support for Education and Training for the Care of People in the Last Days of Life For staff to gain the competencies that are relevant for them in their role, organisations and commissioners may need to consider the following: Co-ordination and organisation of end of life care training What training can be delivered as multi-professional groups Additional training and clinical supervision resources that may be required Any additional resources that may be required to support the required training including backfill of staff to attend training On-going monitoring and review of clinical care in practice across organisations Commissioners An identified lead commissioner for palliative and end of life care who has influence to develop education and training in palliative and end of life care Consider National, regional and local education and training packages available Consider regular reporting around the last days of life education and training within provider organisations. This should be in the context of other support and monitoring of the delivery of high quality care of the person in the last days and hours of life and their family Providers Recognition at board level, through clearly defined support structures, teams and working patterns, that caring for the dying person requires ring fenced time and investment of emotional energy. Employer commitment to ensure the delivery of appropriate end of life education programmes to health and care workers Support staff release for training and education Agreeing which group from those outlined at the start of the document, staff align to. This may not only vary in role but the level of expertise and specialism within that role and proportion of time dedicated within the role caring for the dying person and those important to them. Gaining a baseline of staff skills and competencies outlined in this document to identify priority staff or groups of staff for training and education and base future audit work A pragmatic approach to ensuring all staff are competent in their role to care for the person in the last days and hours of life A blended learning approach to training and education to meet a variety of learning styles. Encouraging reflective practice as part of continuing professional development, and life-long learning whilst meeting the needs of a flexible workforce. Explicit learning outcomes which include how to apply learning to practice, and supports implementation of advice from the Leadership alliance for the care of Dying People. Recognise that conversations about dying and death are difficult and health and care staff need support, and time and opportunity for reflection, if they are to continue to have resilience to do this in an effective and compassionate manner. Support for health and care staff to acquire and maintain the necessary competences for delivering the five Priorities for care of the dying person, commensurate with the individual s role and responsibility, by providing protected learning time and resources for education and training, as part of induction, continuing professional development and regular updates. Consider National, regional and local education and training packages available 16

17 Ensure that health and care staff have access to locally agreed advice for palliative and end of life care based on current best available evidence Evaluation methods which can demonstrate achievement of outcomes and ideally extend beyond the immediate end of the course/training event. Professionals Employee commitment to attend and implement learning from end of life education programmes. Describe the importance of and act upon maintaining own and team resilience through reflective practice and clinical supervision. An appreciation that caring for people in the last days of life is not just about doing or fixing things. It is concerned with supporting the person and those that are important to them during the dying period. Learning Objectives for Training 1 Learning objectives need to be adapted to suit the programme, its duration and format, and its intended learners Depending upon role they should focus from awareness to application to complex assessment and decision-making 17

18 Assessing Individual Professional Competences to Provide Care and Support for the Dying Person in the Last Days and Hours of Life The ten high level statements below are recommended as a framework to underpin all workforce development relating to care in the last days of life irrespective of level of practice, occupational group, or work setting. These statements should be applied within the context of the role and function of the individual professionals following the same principles as outlined in the previous sections of this document. Competences can then be determined and mapped with suitable assessment criteria to reflect the level of skill and performance staff would normally be expected to perform in the role The dying person is at the centre of all planning and delivery of care, including shared decision making, and staff must understand how an individualised care plan is developed and, if appropriate to their role, how to use one. 2. Changes following assessment, including changes in symptoms, must be communicated and understood by all providing care to the person, and staff must know the processes and procedures in place so that information can be shared in a timely and appropriate manner. 3. Staff must understand and be able to act upon the needs of a dying person and take into account the physical, psychological, emotional, social, spiritual, cultural and religious priorities and choices of the person (this may include knowing when to seek advice from other staff.) 4. Staff must understand how they can make the dying person comfortable as their needs change, specifically in relation to food and drink. 5. Staff should understand the benefits of effective, straightforward, sensitive and open communication about dying with the dying person and those important to them, including carers, and staff should also understand the meaning of entitlement to a duty of candour. 6. The dying person s family and those who are important to the dying person, including carers, have care and support needs, and staff must be able to show an understanding of what the needs are and how they can be met. 7. Staff must be able to recognise and review their own needs when caring for individuals who are dying as well as those of the wider care team by using reflective practice and clinical supervision, and be able to communicate when they need further support and development. 8. Staff must understand the principles of the Mental Capacity Act (2005) and how it should be applied when the dying person lacks capacity, as well as the implications for care. 9. The impact of loss and grief on the bereaved must be understood by staff and they should be able to identify support that can be offered. Additionally, for clinicians: 10. They should recognise that dying may be imminent and know their own level of ability to assess reversibility, make appropriate decisions and plans for review, and how to communicate uncertainty Statements to Support the Mapping of Competences to Staffing Roles - Care of the Dying Person Supporting document to One Chance to Get it Right 2014: 18

19 All staff must be able to provide evidence to show they have a level of competency that will be appropriate to their role. This evidence should reflect whether they are statutorily regulated and requiring registration with a professional body, or if they are working at higher or advanced levels. Standards and competences also need to be mapped to local models of care, as roles and functions may differ across organisations and settings to reflect flexible and integrated care of the dying person and their families. Professional Bodies such as the GMC and NMC have education and training standards and guidance with elements of these relevant to care in the last days and hours of life. Both of these organisations, amongst others, were involved in the NHS Leadership Alliance response One Chance to Get it Right 1 When mapping competences and assessment criteria it is also important that staff are able to recognise their own limitations and have the knowledge of where and when to seek expert advice or make a referral. 19

20 Trainers and Educators in Palliative and End of Life Care This section provides guidance for those who educate and train palliative care providers in the delivery of palliative and care in the last days of life, whether within a clinical or purely education role. Qualifications/ Experience in Education and Training and Palliative and Last Days of Life Care Hold relevant experience in their field of Palliative and End of Life Care Maintain an up to date knowledge base of palliative care and other issues relevant to their educator role Completed specific training around their role within the education/ training and support of other professional groups e.g.: Advanced or Enhanced Communication skills training Sage and Thyme training Facilitator Training Hold teaching qualification or level of experience in education / training in the field of end of life care Education and Training Skills Able to deliver education in a formal setting to health and social care professionals with diverse knowledge and skills Ability to deliver formal and informal education and training within a range of formats: Didactic Presentations Seminars Small Group Sessions Case Studies Reflections - Provides feedback that is clear, focussed and aimed at improving specific aspects Experiential learning Coaching and supporting self-directed learning Use of Multimedia training tools such as: Use of PowerPoint Video e-learning Clear and articulate presentation style Understand their role as an influencer on the practice of other professionals within their locality Ability to deal with opportunities and challenges within their education/ training role Guiding and personal and professional development of others within designated role Awareness of different learning and processing styles of multi-professional groups Able to construct a lesson plan with learning outcomes Identifies learning needs and sets educational objectives for multi-professional groups Ability to establish and maintain and environment for learning Involves those being trained in the above processes Current Education and Training Practice in Palliative/ Last Days of Life Care Takes an active role in the palliative care education of health and social care professionals involved in the delivery of palliative and last days of life care. Actively and enthusiastically promote high quality care within their area of expertise Provides a positive role model Ensure and enhance safe and effective care for patients, and those close to them, through training 20

21 Education and training to be evidence based highlighting key research findings Evaluation and Service Improvement linked to Education and Training Undergo regular teaching evaluations Supporting and monitoring educational progress Participate in audit and service improvement To undergo annual appraisal/professional development including their education and training role Trainers who have the expertise to deliver the training may include: o Clinical Specialist Teams o End of Life Care facilitators o Trust education departments o Hospice and other voluntary sector educators It is suggested that at least one trainer per locality specialist team should complete a train the trainer or teaching module such as: o Palliative Care Train the Trainers Course (Liverpool) o PGCE o PTLLS o Train the Trainer for Communication Skills o Other Facilitator Training Trainers should also be able to identify how skills and knowledge to care and manage the clinical situation would be assessed on the completion of training and this may be achieved in a number of ways: Multiple choice answer test Supervised clinical practice 1-2 day placements within Hospice/ Specialist Palliative Care Services Reflection sessions post annual updates for attendees of training 21

22 Appendix 1- e-elca Health Education England are working with stakeholders to develop and influence education and training as appropriate through Health Education England s e-learning for Health (elfh). A library of over 150 highly interactive sessions of e learning on end of life care e-elca has been developed to provide a resource for enhancing the training and education of health and care staff involved in delivering end of life care to people. The sessions are arranged in four core modules (advance care planning; assessment; communications skills; and symptom management, comfort and wellbeing), with three additional modules (social care, bereavement and spirituality) and one integrating learning module which helps to consolidate and apply understanding in different situations. Given the breadth of modules covered in e-elca it is suggested that organisations give consideration to coordinating e-elca education programmes for staff as part of a blended learning approach. Across the Strategic Clinical Network there has been success of implementing e-elca courses where a champion within the organisation has been identified for e-elca and protected time has been given to staff to complete modules. Registration Registration to the e-elca modules can be accessed in a number of ways depending on your role or via the open access website. NHS employees in England If your NHS Trust has implemented e learning through the Electronic Staff Record ESR as part of the National Learning Management System (NLMS) project please speak to your local training and development department, or local ESR system administrator to gain access to e-elca via the NLMS The NLMS is an e-learning platform fully integrated with ESR which means learning can be recorded against your portable employee record. Alternatively if your Trust has not implemented e-learning through ESR as part of the NMLS project, you can access the materials through the e-lfh learning management system (LMS). Go to the e-elca registration page to do this: you will require an NHS e mail account to register Social Care Professionals in England Access to e-elca is available to all social care staff professionals in in England whose employers are registered with the Skills for Care National Minimum Data Set for Social Care (NMDS-SC). Your employer must be registered with NMDS SC for you to register. Every registered employer can get a user registration code for their staff, enabling self-registration for access to e-elca. Please contact your employer for more details about the registration code, and then go to in order to register. Other e learning platforms are available for training in end of life care including the Macmillan Learn Zone. 22