Table 1 Case conference intervention

Patients (61 to 89 years) of a regional general health service with heart failure or chronic lung disease [6] were identified as being at risk dying in the foreseeable future (usualy months), using the ‘surprise question’ [14]. The intent was not to predict prognosis, but to predict escalating need because these patients had a relapsing and remitting course. All patients were under the continuing care of a hospital based cardiologist or respiratory physician. These patients remained decompensated despite being on maximal therapy. The objective was to review the patient from a palliative perspective, plan for expected deterioration, and be ready regardless of when it would happen.

A case conference between the Health service nurse/nurse practitioner, the patient’s GP and a palliative care specialist was convened to generate a clinical care plan. This plan aimed to identify patient and carer needs across clinical, personal and practical domain, and used the PEPSI COLA framework from the British Gold Standards Framework to ensure all domains were considered [15]. The nurse discussed the patient and carer needs with them and represented their views at the conference. Both nurse and and GP prepared for the meeting by reviewing the case notes. Case conferences took place either in the GP surgery or by teleconference. The Palliative care specialist acted as the conference chair and provided advice as needed. He did not see the patient unless that was an element of the plan. A written plan was generated which identified issues, what had to be done and the clinician responsible. The plan was reviewed by the patient and carer and the nurse, and endorsed or modified before being actioned. All participants, the patient and carer received a copy.