electronic Palliative Approach Framework

Phase: Stable (care needs controlled with existing plan of care)
Prognosis: Last year of life
Key clinical process: ADVANCE CARE PLANNING

Holistic MDT assessment and care plan
  • Patient/carer holistic needs assessment
    (including physical, psychological, emotional, social, spiritual and cultural domains)
  • Determine goals of care & instigate holistic care plan

Communication
  • Communicate with patient and carer
  • Provide ‘palliative approach’ information leaflet

Advance care planning
Symptom management
Equipment provision
  • Provide aids and equipment, if required
  • Refer to allied health team, if required

Carer support
  • Register for carer respite
  • Apply for carer allowance +/- payment
  • Refer to home care services, if required

For patients with complex needs
  • Refer to Specialist Palliative Care (SPC) Team
  • Discuss at Specialist Palliative Care MDT Meeting
  • 24/7 Palliative Care on-call service, if available

electronic Palliative Approach Framework

Phase: Unstable (potentially reversible deterioration with uncertain recovery and prognosis, requiring urgent review of plan of care)
Prognosis: Uncertain
Key clinical process: Urgent assessment and management of potentially reversible deterioration in line with wishes and goals of care

Unstable
  • Urgent assessment and treatment of potentially reversible deterioration in line with wishes and advance care planning
  • Frequent reassessment, review of goals of care and communication with patient and carer
  • If in hospital, consider initiating AMBER Care Bundle

electronic Palliative Approach Framework

Phase: Deteriorating (decline in overall functional status, with gradual worsening of existing and/or anticipate problems, requiring periodic review of plan of care)
Prognosis: Last months - weeks of life
Key clinical processes: Anticipatory care planning and MDT care coordination

Holistic MDT assessment and care plan
  • Reassess holistic care needs frequently
  • Review goals of care and holistic care plan to address current and future anticipated need
  • Discussion at MDT Case Conference

Communication
Advance care planning
Symptom management
Equipment provision
  • Provide aids and equipment
  • Refer to allied health team, if required

Carer support
  • Initiate carer respite, if required
  • Refer to home care service, if required

For patients with complex needs
  • Refer to Specialist Palliative Care (SPC) Team
  • Discuss at Specialist Palliative Care MDT Meeting
  • 24/7 Palliative Care on-call service, if available

electronic Palliative Approach Framework

Phase: Terminal
Prognosis: Last days of life
Key clinical process: Comfort care in the last days of life

Holistic MDT assessment and care plan
  • Reassess care needs at least daily
  • Review care plan, in line with goals of care
  • Initiate Last Days of Life Toolkit
    or Residential Aged Care End of Life Pathway

Last days of life toolkit

Residential aged care end of life pathway

Communication
  • Communicate with patient and carer
  • Provide ‘last days of life’ information leaflet

Provide care in line with advance care plan
  • Confirm Preferred Place of Death (PPD) and consider transfer if appropriate
  • Complete Resuscitation Plan, if not already done
  • Complete Ambulance Plan, if not already done
  • Complete Expected Death form, if at home and not already done

Resuscitation Plan Documents

Ambulance Plan Documents

Expected Home Death Documents

Symptom management in the last days of life
Equipment provision
Carer support
  • Refer to home care services, if required
  • Provide carer medical certificates, if needed
  • Identify carers ‘at risk’ of bereavement

For patients with complex needs
  • Refer to Specialist Palliative Care (SPC) Team
  • Discuss at Specialist Palliative Care MDT Meeting
  • 24/7 Palliative Care on-call service, if available

electronic Palliative Approach Framework

Phase: Bereavement
Timeframe: Days, weeks and months after death
Key clinical process: Care after death and bereavement support

Care after death
  • Undertake verification of death
  • Complete Coroner’s Checklist
  • Complete Medical Certificate of Cause of Death
  • Completed Attending Practitioner’s Cremation Certificate, if required
  • Provide after death care

Care after death

Verification of death

Coroners checklist

Medical certificate of cause of death

Cremation certificate

Provide after death care

Communication
  • Communicate with family and carers
  • Provide bereavement information to carer

Bereavement information

Bereavement Support
MDT Communication and reflection
  • Notify healthcare professionals involved
  • Wider MDT reflection and debrief, if required
  • For deaths in hospital: Complete CEC death screen
  • For deaths known to Specialist Palliative Care:
    After Death Discussion at SPC MDT Meeting


WNSW Primary Health Network
Western NSW LHD
Far Western LHD