Developing individual care plans and goals for every end of life care patient

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1 Developing individual care plans and goals for every end of life care patient Dr. Dee Traue Consultant in Palliative Medicine

2 We will cover How individual care plans differ from the LCP Developing and monitoring care plans for every patient and communicating with family and carers Ensuring the individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion Our experience

3 How individual care plans differ from the LCP

4 End of life care plans The Review panel strongly recommends that use of the Liverpool Care Pathway be replaced within the next six to 12 months by an end of life care plan for each patient

5 What s in a name? Care Plan For people with long-term conditions. It is an agreement between the patient and health professionals to help manage the patients health day to day Integrated care plan Similar to a care plan but detail the clinical steps in the care of patients with a clinical condition

6 What s in a name? Pathway A management tool for health professionals for specific patients with a predictable clinical course where the different interventions are defined, optimised and sequenced The LCP was a pathway that focused on the last days of life

7 What s in a name? Patients are classed as reaching the end of life when they are likely to die within the next 12 months

8 What s in a name? Focuses on the relief of pain and other symptoms and problems experienced in serious illness

9 What s in a name? The Dying Person - In the last few days and hours of life

10

11 Personalised Palliative Care Plans Anybody who has a progressive life-limiting illness should be offered the opportunity to develop, document, review and update a Personal Palliative Care Plan This should be developed over a period of time in response to the person s wishes and readiness to discuss these matters

12 Personalised Palliative Care Plans This is simply a collection of a variety of plans which already exist for many people in this situation advance care plans emergency care plans information about that individual s wishes about his / her care and treatment wishes about care in the last days of life

13

14

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16 One Chance to Get it Right Generic protocols are not the right approach to caring for dying people: care should be individualised and reflect the needs and preferences of the dying person and those who are important to them

17 Priorities for Care of the Dying Person An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion

18 Beds & Herts Cancer Network Pilot

19 Who? A plan for care and treatment must be developed to meet the dying person s own needs and wishes in relation to how their care should be managed and any treatment preferences they may want to express.

20 Individual plan of care for the dying person

21 Where? This plan of care must be documented so that consistent information about the person s needs and wishes is shared with those involved in the person s care and available at the time this information is needed.

22 Where?

23 What?

24 What? This plan must include attention to symptom control (e.g. relief of pain and other discomforts) The panel also took evidence that opiate pain killers and tranquillisers had been used inappropriately and was concerned that, in some cases, these drugs were given as a matter of course, rather than from a need for symptom control.

25 What? The person must be supported to eat and drink as long as they wish to do so Food and drink can be important to people s comfort and psychological wellbeing, even where their physical needs for hydration and nutrition are met through other means

26 The person s physical, emotional, psychological, social, spiritual, cultural and religious needs. What?

27

28 There must be prompt referral to, and input from, specialist palliative care for any patient and situation that requires this.

29 The care plan should be reviewed as circumstances, including the dying person s preferences, change

30 When?

31 Transforming participation in health and care In many cases people will already be receiving care and the care plan for their last few days and hours of life will be part of a planning process that started days, weeks, months or even years before

32 Communication Sensitive communication takes place between staff and the dying person, and those identified as important to them

33 Culture of care

34 Culture of care the NHS. The Francis report has begun the process of redefining compassion at the heart of care

35 Communication A crucial component of providing quality and compassionate care is the way healthcare professionals communicate with patients and their families and involve them in the decision-making process

36

37 Communication The senior clinician should write in the patient s notes a record of the face to face conversation in which the end of life care plan was first discussed with the patient s relatives or carers

38

39

40 Beds & Herts Cancer Network Pilot sites Pilot Lister Hospital (acute trust) 10 patients Michael Sobell House (cancer centre) 12 patents Peace Hospice Care (independent hospice) 5 patients Education and training provided to the clinical areas prior to the pilot

41 Beds & Herts Cancer Network Pilot Medical Management Plan / Daily Senior Clinical Review As long as it has been explained the person is dying it shouldn t be necessary to say they are on a specific care plan Too great an emphasis on doctors to do all the communicating Concerns on expectation that doctors will assess emotional and spiritual needs Comfort Sheet Generally positive but some concerns Too much paperwork Hourly assessments not achievable (even if linked to intentional rounding) Needs better link with medical section

42

43 The challenge for the NHS is to provide a framework that ensures that care provided to people in the last days and hours of life is of high quality and is based on individual needs.

44

45 Next steps National implementation of the Priorities and plans Education and training Develop evidence base Review professional standards CQC monitoring NICE guidance

46

BGS Response to LACDP System Wide Response (www.gov.uk)

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