End of life care: Working in teams and across service boundaries

1. 22. Most treatment and care at the end of life is delivered by multi-disciplinary and multi-agency teams, working together to meet the needs of patients as they move between different health and social care settings and access different services. This can include GP practices, local care homes, pharmacies, hospices, ambulance services, local hospitals, and local authority and voluntary sector support services. You must communicate effectively with other members of the health and social care team or teams involved in a patient’s care, sharing with them the information necessary to provide the patient with safe, effective and timely care. (See paragraphs 75-77 on recording and communicating decisions.) When considering options for treatment and care, and reviewing the patient’s progress, you should consult other members of the team who may have information about the patient or relevant knowledge and experience that may help in managing or treating the patient’s condition.
2. 23. You must make sure that you understand the scope and responsibilities of your own role in the healthcare team, the roles and specialist skills of other health and social care team members, and the lines of accountability for the patient’s care.¹⁷ You should take steps to clarify any ambiguity about your own or others’ responsibilities with your employing or contracting organisation if you have concerns that the ambiguity may compromise patient safety.¹⁸