Needs assessment

When a palliative care approach is recommended, a comprehensive assessment of needs should be undertaken. People with advanced lung cancer may be at risk of sudden deterioration through direct or indirect complications of their disease. Proactive and responsive care is necessary to support people at different phases of their illness and as they approach end of life. Future care planning (previously known as Advance care planning) helps people plan this care together with health professionals in line with what is most important to them. The following are recommended elements of needs assessment.

Palliative Cancer Care Summary

Documenting, details on the person’s diagnosis, their understanding of this, who and what is important to them, their current needs and an immediate plan. This may have different formats in different regions e.g. clinic letter or future care plan. Shared with the Primary Care Team (GP and DNs) via email and uploaded to the local Clinical Portal/other Secondary Care system. A prompt to the GP is included to complete an eKIS (or equivalent). This may be completed by the Cancer CNS, but it may be another experienced clinician in their current care team.

Future Care Plan

The diagnosis of incurable lung cancer should trigger completion of a future care plan. This is a dynamic record of the person’s wishes and preferences about current and future care based on shared decision making with the person, those close to them and a health care professional. The plan may include:

• Concerns and goals
• Understanding about their illness and prognosis
• Wishes for end of life care, views about level of interventions, treatments, and cardiopulmonary resuscitation.

Conversations around future care should consider legal and practical issues e.g. Power of attorney. Plans should be revisited regularly as people’s views may change as their condition progresses and different things may take priority. The future care plan should be shared with health professionals involved and available on their electronic record. The GP should be informed to update the Emergency Care Summary (ECS) so that clinicians and emergency services can access these details.

Holistic Needs Assessment

All patients are offered referral to Macmillan Support Worker Services (sometime known as Improving the Cancer Journey team). Support available around financial, work or housing concerns.

Responsive Care

Person-centred responsive care should be available to support people with advanced lung cancer and those close to them as their condition progresses. Patients and care givers should have:

• Access to community Allied Health Professional teams (including dietetics, physiotherapy and occupational therapy) to allow assessment for walking aids, home modifications and equipment. Consideration should be given to anticipated functional decline in weeks to months following diagnosis.
• Timely access to prescriptions with the option of home delivery and should have written instructions around medications including any changes.
• Rapid access to social carers to assist with personal care at home.
• Access to oxygen if required regardless of setting.
• Patients in last weeks of life or at risk of sudden deterioration should have ‘just in case’ medications and community Kardex.

Referral to Specialist Palliative Care (SPC)

Patients with more complex physical or psychosocial needs can be referred to their local multi-professional specialist palliative care team. Specialist services are configured differently across Scotland and may include inpatient beds, outpatient clinics, hospital and community teams. Specialist Palliative care telephone advice and support is available 24/7 in any setting.