“I have great gratitude for this professional team”

When Edward, a client living with Motor Neurone Disease (MND), was hospitalised with COVID-19, his family faced significant concerns about his overall deterioration and likelihood of returning home safely. After a long hospitalisation, Edward was eventually discharged home at end-of-life care phase, as no more active treatment was suitable.

Previously Edward’s complex care needs were successfully managed at home, but with his increased breathlessness and a hospital acquired pressure sore, additional help was required to improve and stabilise his overall comfort and condition.

Significantly, Edward’s communication presented some challenges. Whilst he understood everything, his verbal communication was sometimes difficult to interpret. To address this, Edward used a watch-like button to easily summon assistance when needed, empowering him to maintain a sense of control. Staff were reminded to anticipate and look to Edwards body language to sense how he was feeling and always speak to Edward prior to any treatment. The family’s consistent presence allowed them to effectively support and assist staff.

Once contacted, Cavendish Homecare swiftly stepped in to provide crucial support during this challenging time, offering reassurance and a comprehensive care plan tailored to Edward’s specific needs so that he could return home as soon as possible.

Our Client’s Story…

Recognising the urgency of Edward’s condition, Cavendish Homecare assembled a dedicated team under the guidance of an experienced Nurse Manager. They ensured all extra equipment was sourced and available at home.

They were able to provide essential hands-on care, including frequent repositioning and meticulous pressure sore management. Beyond the physical aspects, the team also offered invaluable emotional support to Edward and his family, understanding the anxieties associated with managing complex end-of-life care at home.

A proactive approach was taken to ensure seamless coordination with other healthcare professionals. Despite the initial absence of a clear GP support plan, Cavendish Homecare took the initiative to establish regular multidisciplinary team (MDT) meetings. These facilitated effective collaboration with the District Nurse team, who regularly attended to support the care team with Edward’s catheter management and skin integrity to heal his pressure sore.

Also, arrangements were made for a visiting chiropodist to attend for essential foot care, all part of Edward’s well-being. These joint efforts ensured a holistic approach to Edward’s care, helping him live well at home for as long as possible, despite his condition.

The Cavendish Approach…

The care plan implemented by Cavendish Homecare was adapted to Edward’s evolving needs. Initially, two carers provided daily support. However, as Edward’s breathlessness increased, the team recognised the need for adjustments. Cavendish Homecare staff supported Edward attend specialist neurology and respiratory appointments. During these appointments, Edward’s respiratory support was reviewed, and machine settings were made to suit his changing needs.

The individualised care package included supporting Edward access community facilities such as restaurants during family meal outings. Edward was given space to spend quality time with his family and particularly enjoyed doing activities with his granddaughter.

To prevent further strain and reduce the risk of falls, transfers from his bed to a reclining chair were facilitated using a wheelchair. Eventually, even short movements and getting up required the assistance of two carers plus suitable equipment for safety and comfort.

Whilst this wasn’t a post-operative case requiring a pain diary, the team remained vigilant in observing Edward’s comfort levels and communicating any concerns to the wider MDT.

A cornerstone of palliative care is ensuring clients are as pain-free as possible through regular and proactive analgesia. As Edward’s condition progressed, he became bedbound.  He also had greater difficulty speaking and expectorating, and with a decreased appetite.

The care plan continued to adapt, with emphasis on repositioning whilst in bed to protect his skin areas. Hoisting was also introduced to assist with commode use, prioritising Edward’s safety and dignity.

As Edward’s condition deteriorated further, the Cavendish Homecare team worked closely with the hospice staff. When suitable, a syringe driver was set up by to ensure Edward remained comfortable during his end-of-life phase. The hospice team and Cavendish Homecare staff worked together to share information and ensure Edward received the very best care experience.

The Outcome…

Sadly, approximately a year and a half after the initial enquiry, Edward passed away peacefully, surrounded by his loving family. The team of carers who had become an integral part of his care were also able to say their goodbyes, highlighting the strong bonds formed.

Cavendish Homecare evidenced best practice throughout Edward’s care – ensuring his needs were met and that that he remained comfortable and pain free- ensuring his wishes were always met.

Cavendish Homecare’s focus extended beyond physical care to encompass emotional well-being and maintaining Edward’s quality of life. This aligns with a “Lantern model” of palliative care, highlighting the individual’s needs and preferences at the centre of the holistic care plan.

This model also supports staff in their workplace, as they accompanied Edward and his family during his end-of-life journey.

Disclaimer: For privacy and confidentiality reasons, the names and locations in this case study have been changed. The events and outcomes described are based on real situations, but identifying details have been altered.