Palliative Care

I completed my FY1 and FY2 years and started my CMT as I wanted to do dermatology but then I realised that this was not what I wanted to do so I left the CMT programme and applied for GP training in Watford. Even when I joined the GP training I had the aim to work in dermatology but I didn’t get allocated the dermatology innovative job.

I ended up doing the innovative post at the Hospice of St Francis in ST1 and absolutely loved it. When I began, I didn’t know what palliative care was, we think it’s just end of life care and keeping people comfortable and that maybe your work doesn’t have that big an impact. It was a completely different realm of medicine. I realised how much of an impact it has, whether it’s palliative rehab or symptom control for people with long term conditions and I hadn’t realised how holistic it was. It was the patient and their family and children as well as their social situation which also fits in so nicely with being a GP as you are someone in their community life and working in a hospice is almost a stepping stone between primary and secondary care. I absolutely loved it.

I wasn’t going to change my pathway from being a GP but I still wanted to spend more time in palliative care. I didn’t really want to work as a locum either so when I finished my GP training I asked how I could still be involved. I stayed in touch with the consultants at the Hospice and would attend educational sessions. I also completed the European Certificate in Palliative Care and got involved in teaching. Through keeping in contact with the staff I worked with, I have now started working at the Michael Sobell Hospice which is attached to Mount Vernon. I do that once a month and it’s a 48 hour on call shifts (from Friday evening 9pm until Sunday evening 9pm). They also have an MDT every Wednesday and I sometimes join in as well as if there are any external speakers or interesting cases being discussed. 

I qualified from West Herts GP training scheme in August, I started at the Lodge in September as a salaried GP and I’ve just become a partner in January.

The Michael Sobell Hospice is a 12 bed in patient unit but at the moment due to COVID the maximum number of patients we have is 10.

On a Friday evening I receive a handover and patient list on my NHS email and then I’ll call the unit and get a verbal handover from the GP who has been there during the week (these are SHOs – GP trainees completing their innovative posts through the Hillingdon scheme).

At around 9:30 pm I’ll call the in-patient unit after they’ve done their evening handover and checks on the patients and I’ll get a handover from them. It’s not often that I’ve needed to go in on a Friday but sometimes there will be complex patients. I’m also the end of the hotline so sometimes I’ll get calls from 111 or from the district nurses

On Saturday I don’t go in until 11 am as the day team needs some time to do medications. I complete the ward round and, because they’re complex patients on complex medications, I’m usually there until around 4pm, sometimes it’s a bit longer. I spend a lot of time with the patients and their families and these conversations can take about half an hour and there may be multiple conversations, especially if the patient is end of life.

When everything is fine I’ll go but still be available on the telephone. Sunday is a repeat of Saturday and then at around 9pm I do a handover to the consultant.

The unit tries not to have admissions on weekends, these only happen in an emergency.

Yes, there will always be a consultant available on the telephone and we get the rota of who is available during the week. I’ve found that the consultants are always very easy to get hold of and I’m always able to ask for help when I need it. In this hospice I feel very supported.

Working in the Hospice is a commitment, it’s your job and you need to have indemnity cover for it.

One can do the certificate, it will give some information. It’s not just for doctors but nurses and pharmacists also complete it. There are some educational session that need to be attended and you need to complete a 1,500 work case study on a palliative patient where you discuss the things you have learned, the wider holistic care of the patient as well as their medications. There are also two exams to be completed; a VIVA and a written exam. You need to achieve almost 100% in the written exam as it is about strong medications and you can’t make any mistakes. This exam is mainly medication calculations.

The certificate is useful to complete as it helps to consolidate your knowledge and makes it formal. You also have a supervisor and have the opportunity to be part of the MDT however, you wouldn’t necessarily get a job anywhere because of it.

If you are interested in working in palliative care you can:

• Link in with the palliative care leads in your surgery or join palliative care meetings

• Work closely with the palliative nurses in the area

• Join educational programmes run by the hospices (Hospice of St Francis has a lot of things you can sign up for on their website and they also have an educational centre). Many of the educational sessions are for free

• Attend conferences

I’m actually neither of those two in my practice, we have someone else who has been doing palliative care for a long time and is very good at it. But I definitely think that other than those formal roles, it definitely gives a different perspective on approaching patients. I know that these cases can be very complex and daunting. Even just prescribing the medications can be very complex and we don’t deal with these day to day so working in palliative care has given me more confidence around this. It has also helped me know about the other options of medications that can be prescribed as well as how to approach the patients and knowing about the different kinds of pain (not just physical but also mental).

It gives patients more confidence in me as I can tell them that I work in a hospice on weekends and it has also given me that opportunity to work closely with the community nurses. Overall I have gained confidence when seeing these patients as well as knowing the scope of what is possible when treating them.

It’s also useful to know where you can go to for additional resources. The Herts Valleys CCG has a good online resource and there is also a website called palcare.info which talks about the different medications you can prescribe and how they act on the patient. A lot of us have no idea about these medications as we don’t use them day-to-day as we don’t see these patients day-to-day. It makes you more confident in your decision-making.

I think one would first have to decide whether one wants to work in a hospice. It’s not an easy job and it takes a certain personality. It is an environment where patients die or are very unwell.

If you decide that you do want to work in a hospice then I suggest that you find out who the consultants are and which hospices are in the area. It would be good for you to make contact with them and say that you have an interest in palliative care. You could ask to join an MDT meeting or patient discussion as there are often many interesting cases being discussed.

If you decide that you don’t want to do it as a job then it’s about expanding your knowledge and exposure. You can attend palliative care meetings or attend some educational sessions.

Hospice of St Francis Educational Events:

https://www.stfrancis.org.uk/clinicians/programme-of-events?gclid=CjwKCAiAsOmABhAwEiwAEBR0Zto7VP6mMZPnpRcFeJWorC7jYD4JiKiyJHom07ABhJdrDsgjHZ7EIhoCdFwQAvD_BwE

The first thing I found difficult was working out what to do about indemnity cover. I contacted my current provider who didn’t know what to do about it and the discussions went on for months. It was very difficult as I found that there was no guidance and no one to ask. Eventually I managed to sort it out.

I also find that some weekends are very mentally draining. If you did do the weekend work at a hospice I would suggest taking the Monday or Monday morning off at least. Your brain needs to ‘download.’ It’s not just the physical strain of being on your feet all day (compared to general practice where you’re generally sitting) but at the hospice people offload their worries onto you.

You will also need to make your own effort to keep yourself up to date with new things. I’m lucky that, in hospice, there’s a whatsapp group and the consultant will send around information to us but this may not happen everywhere. You will have to make the extra effort to keep up with your own reading.

It helps you to manage conditions that are seen and managed regularly in general practice but may not be as common at the hospice for example; skin lesions, BP and diabetes. It is also useful to be able to tell patients that we know what their experience may have been like along their journey which may have started in general practice when they first presented with their condition. The patient therefore knows that you understand what their journey has been like.  

It is also useful as I often get questions from relatives asking about things such as gynaecological issues or mental health which we also treat. I find it gives me additional insight.  

One other thing that’s been useful for me to learn about is completing death certificates. I have become a lot more comfortable completing these.

Being in the hospice, I have always enjoyed the work as you get to see the impact it has on families and the thank you is great. During COVID this has escalated. In hospital, patients are often by themselves but in the hospice they have allowed relatives in with certain rules.

All of the rooms are linked to a window so even if their relatives can’t go in they can sit outside. These are small touches that you often don’t get in hospital.

COVID has restricted what we can do but relatives can be with their loved ones and can be with them at all hours.

On a wider scale, the hospice is a place of gratitude. It’s not often you see patients so grateful. There will be drawings and letters and it is all very heart-warming to be in that environment. The spirit of everyone working there is also lovely.

I was surprised to discover that only 25% of the funding comes from the NHS, the rest comes from fundraising and St Francis hospice has its own fundraising team. Due to COVID, many of these events have stopped but I haven’t noticed a difference and I haven’t been in a situation where there I haven’t had the resources I needed. The basics of what is needed to care for the patients are there.