South West Yorkshire Mental Health NHS Trust

Care Plan: Smoking

 

Goals

 

  1. For me to be aware of the current ‘smokefree’ policy and adhere to its contents

 

  1. For me to be aware of the support available with stopping smoking, and how to access these services

 

  1. For me to be aware of the various products available to help with nicotine withdrawal and to be supported in obtaining these

 

 

Things the staff will do to help me are….

 

  1. To inform me on admission about the Smokefree Policy and to help me understand the contents of the policy

 

  1. To work with me to help my adherence to the policy for the duration my admission

 

  1. To inform all my visitors of the Smokefree Policy and ensure they also adhere to the policy  

 

  1. If my visitors are distressed, they will be offered support and comforted by ward staff, though the policy must be maintained

 

  1. To give me informative and educative information with regards to the risks involved in smoking. These include:

 

  • Smoking increases the risk of  coronary heart disease by 50-60%
  • Smokers have higher rates of and suffer more severe depression
  • Smokers are more likely to think about suicide and have a higher rate of suicide
  • Heavy smoking is associated with more severe psychotic and schizophrenic illness, and more frequent admissions
  • Smokers need higher doses of antipsychotics (by up to 50%)

 

And the risks involved to passive smokers. These include;

 

  • Passive smoking kills 1200 people a year
  • Passive smoking increases the risk of lung cancer and ischaemic heart disease by 25%
  • Heavy passive smoking carries the same risks as light smoking, including increasing the risk of coronary heart disease by 50-60%

 

  1. To provide information about the smoking cessation service, ascertain as to whether this service is wanted, and, complete a referral if required

 

  1. To provide me with information on the different types of aids available to help me stop smoking. These include:

 

  • Trans-dermal patches \
  • Lozenges                      \
  • Gum                             / collectively known as nicotine replacement therapy
  • Inhalators                   /

Including information about what is available on prescription, and to help me           obtain these if required.

 

  1. If I am assessed as being exempt from the Smoke free Policy i.e. if I am newly detained under the Mental Health Act, this will be clearly documented in my notes with the reason(s) for the exemption.

 

  1. To make me aware that smoking affects the absorption of some medications, like Olanzapine and Clozaril, and that this may mean I need a higher dose.

 

 

 

 

Please Note

 

If I am assessed as being exempt, I will only be allowed to smoke in the designated area and at agreed times.  There will be no smoking between 11.30 pm and 7.30 am.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flow Chart indicating Support for Patients who Smoke

 

Does your patient smoke?

 
 

 

 


On Discharge

·   Refer to Specialist Service by completing Minimum Data Sets and forwarding to the address at bottom of form.

·   Inform them that the stop smoking service will contact them.

·   Give 4 weeks supply of NRT at discharge.

 

·         Offer Nicotine Replacement Therapy for relief of withdrawal symptoms

 

·         Discuss the benefits of stopping smoking.

 

·         Offer information on the Specialist Service so they can self refer if they would like to stop in the future

 

IT IS NEVER TOO LATE TO STOP SMOKING

 
  • Offer Nicotine Replacement Therapy for relief of withdrawal symptoms.
  • Offer continued support to remain stopped after discharge.
 

IF YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smoking Exemption Assessment

 

To be completed as part of the admission process and the decision arrived at following consultation with the nursing and MDT.  It is applied on a case by case basis and no one is granted “automatic” exemption, see Exemptions Procedure below.

 

 

                                                                                                                        Yes      No

 


1.         Does the person smoke?        

 

2.         Number smoked per day        

 


3.         Has the Smoke Free Policy been explained to the person?               

 

4.         Response to Smoke Free Policy

 

 


                                                                                                                                               

 

           

 


4.                  Does the person fulfil the criteria under the exemption policy?                    

 

 

6.         Evidence/criteria for this

 

           

 

 

 

 

 

 


7.         If exemption not appropriate, has Nicotine Replacement Therapy

            (NRT) been offered and discussed?                                      

 

 

8.         Staff involved in assessment (list)     

 

 

 

 

 

 

 

 


Following the assessment a care plan should be formulated and regularly reviewed

 

Procedure for Exemptions Under the Smoke Free Policy

 

 

Introduction

 

The Department of Health has declared that the National Health Service (NHS) in England and Wales will be smoke free by December 2006. This is a Health and Safety measure, with particular concerns about the dangers of second hand smoke.  Such a policy presents challenges within psychiatric settings, particularly in-patient units.

 

The Trust has a role of ensuring the physical, as well as the mental health of service users. Although it is generally acknowledged that a total ban sends a strong message to all, there are obvious problems with its implementation in some in-patient psychiatric settings, such as intensive care units, substance misuse services, locked forensic wards, challenging behaviour units and long stay residential services. Certain service user groups present similar challenges, particularly those in the acute phase of their illness.

 

Although the White Paper Choosing Health: Making Healthy Choices Easier (DOD 2004b) states that ‘no blanket exceptions will be allowed, for particular categories of patients’, certain exemptions are inevitable and their management can influence the success or failure of the policy.

 

It is likely that having exemptions to the Smoke Free Policy is a transitional arrangement and that in the future there may be no exemptions.    This may be due to Government guidance changes, or because of feedback the Trust receives about how well these rules are working for people who use its services. If the Trust does need to make any changes to the guidance it will ensure that the appropriate people are fully informed.  The position regarding exemptions will be reviewed after six months. 

 

It is acknowledged that there may be factors within services/localities which require exemptions to be flexible and responsive, for example to take account of environmental factors.

 

Exemptions

 

The Trust Board agreed the Smoke Free Policy* in April 2006. The Policy recognises that some service users have circumstances that will require staff to make an assessment as to whether special arrangements need to be made so that the service user will be permitted to smoke on a Trust site; this being determined on a case-by-case basis.

 

Possible exemptions may be when a service user is:

 

• allowed to smoke following a risk assessment; where a significant risk is identified

 

• allowed to smoke when newly detained under the Mental Health Act

 

• unable to understand the Policy (cognitively impaired)

 

• unable to access Nicotine Replacement Therapy

 

 

 

 

Process

 

Permission to grant an exemption will rest with the multi disciplinary team (MDT) and be formally recorded and individually care planned. If the MDT is not available at the time of admission, then the nurse in charge and the admitting doctor will make the appropriate decisions regarding whether an exemption should be allowed. This may include using Nicotine Replacement Therapy (NRT), which will normally be subject to the Symptomatic Relief Protocol (SRP). 

 

The SRP enables NRT to be part of routine discussion with all service users who are admitted and who smoke. They will then be aware that they are not permitted to smoke on NHS premises, they are offered NRT and offered structured assistance to give up if they so wish.  Any exemptions allowed on admission, will be reviewed after a period of three days and will only continue if there are good reasons noted in the risk assessment.  The exemption will then be reviewed regularly as the whether it continues, the assessment being fully documented.

 

In all cases where an exemption has been made there should be demonstrable evidence that smoking cessation has been fully considered as part of the patient care pathway, in conjunction with the service user and/or their relatives.

 

Where an exemption is made, every effort must be made to minimise staff exposure to second hand smoke. This would normally mean that smoking would only be permitted outdoors where staff and other service users would not be in close proximity to the smoker. Ideally, this would also be out of sight of other service users, visitors and staff, who may be engaged in a smoking cessation programme.

 

Consistency in the application of exemptions is essential, if implementation is inconsistent or fragmented, it may lead to conflict in various forms. Clinicians must ensure that requests by service users to smoke do not become ‘negotiated smoking privileges’.

 

Smoking will not be allowed for those with exemptions between the hours of 11.30 pm and 7.30 am.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Available on the Trust’s intranet