To provide specialist nursing services for people with specialist palliative care needs, including their families and significant others. To accept responsibility for own patient caseload, ensuring all patients have an accurate plan of care, which reflects the assessment undertaken and incorporates the issues and recommendations made To accept responsibility as the named palliative care key worker, ensuring clear documentation in the patients records To co-ordinate a seamless service through the development of enhanced Multidisciplinary team (MDT) processes and communication To attend and ensure that appropriate palliative care patients on the caseload are discussed at the weekly MDT To liaise with local community, social services, paramedics and voluntary organisations in order to develop existing services for clients, carers and health professional Ensure all patients receive appropriate follow-up and relevant information is available to enable patients to make an informed choice about their treatment and future care To work with the MDT to develop, implement and evaluate integrated care pathways and systems of MDT documentation, including the care of the dying person To work with the Palliative Care Team to support the ongoing implementation of the 5 priorities for care of the dying person To be responsible for identifying and developing clinical protocols and strategies to enhance both the continuity and standard of specialist care whilst ensuring equity of access to the service To actively involve service users in providing feedback of their experience of the current service and suggestions for improvements To liaise with discharge coordinators and ward staff to ensure appropriate and timely discharge/follow-up arrangement in place for patients To participate in relevant forums at Care Group, Trust, CCG, Cancer Network or National/International Level to represent the service perspective