Setting the scene

64 year old man (Tim Nelson) newly diagnosed with – non malignant condition with an indeterminate prognosis -posing a high degree of uncertainty about the future and care planning – possibility of being in the last year of life – The condition for the purpose of the case study is pulmonary fibrosis but the trajectory may be similar to other chronic conditions such as cardiac failure or Chronic Obstructive Pulmonary Disease (COPD) therefore similar conversations may take place

Some things to know about Tim

His personal life:

  • wife died 2 years ago – killed in car accident
  • recently retired engineer
  • lives alone – 2 daughters (Sasha – lives 60 miles away and Laura lives along the road – very caring but both have busy lives with full time careers – 5 grandchildren – an estranged son (Kirk) from a previous marriage – another 2 grandchildren who do not know him very well at all
  • prior to this diagnosis, his health had been good but he was a smoker and enjoyed a few drinks on a Friday in the local pub – he had played bowls since retiring as well as his golf
  • really struggling with the loss of his wife – guilt over his relationship with the son.

He had not visited the GP for many months but in the last 8 months of life had:

  • 20 GP contacts, (6 in his home with 4 of those OOH)
  • 3 hospital admissions (died in hospital on final admission)
  • 36 District Nurse (DN) contacts – weekly for 2 months with initial contact to support home oxygen being put in place as per hospital team advice- then daily for 2 weeks – twice daily for 1 week
  • DN also had tel contact with patient and relatives x 6 and liaising between teams x 8 and a final visit following death as a Bereavement visit to family
  • social care package introduced as disability increased – 2 visits per day for 2 weeks – increased to 4 times per day for 2 days prior to final admission
  • gaps in service overnight.