Background Our hospice currently runs a programme of day therapy for patient with any life-limiting illness. We have previously undertaken a fatigue, anxiety and breathlessness pilot for patients with chronic obstructive pulmonary disease, and work collaboratively with our acute and community trusts supporting a weekly multi-disciplinary team (MDT) meeting to identify patients admitted to hospital potentially in the last year of life, to promote advance care planning discussions. There is an ever increasing emphasis on care which is individualised to patients and their condition(s).

Aims To develop a tailored approach to the support of patients with specific conditions, initially focussing on end stage respiratory diseases, and to demonstrate that this enhances the benefits for patients and their families.

The programme

• 12 month pilot

• 10 week programme of care

• Initial assessment by a member of the hospice palliative care team

• Weekly review by a senior nurse

• Nurse-led follow up clinic, one month after completion with a telephone consultation three months later

• Education and self-management fundamental to the programme. Weekly education sessions for patients and their family/carers, covering management of fatigue, anxiety, breathlessness, nutrition and a session titled ‘understanding your lungs’ to enhance understanding of diagnosis

• Monthly collaborative MDT with acute and community colleagues.

Evaluation The evaluation of this programme will be undertaken throughout and includes:

• Impact on symptom control and quality of life using the Outcome Assessment and Complexity Collaborative toolkit

• Evaluation of education including confidence managing symptoms (patient and family/carers)

• Number of admissions in the 12 months prior to, during and up to six months after commencing the programme

• Number of patients on supportive care registers pre and post programme

• Achieving preferred place of death.

Conclusion Following evaluation of this new approach, we hope to explore if it is applicable to patients suffering other conditions and with robust outcome data, provide evidence for on-going funding.