Palliative and End of Life Care Bundle Nothing About Me Without Me. Involving People in Planning Their Care. Dundee Community Nursing 71 Lothian Road Dundee 01382 513104 dnadultservices.tayside@nhs.net
DUNDEE HEALTH AND SOCIAL CARE INTEGRATED PALLIATIVE AND END OF LIFE CARE BUNDLE Useful Websites Palliative and end of life care is provided by health and social care professionals to those living with and dying from any advanced, progressive incurable disease. Good palliative care is not just about supporting someone in the last months, days and hours of life but about enhancing the quality of life for both the person and their families. It focuses on the person not the disease and applies a holistic approach to meeting the physical, practical, functional, social, emotional and spiritual needs of the person and their carers facing progressive illness and bereavement (NHS Scotland,2015). This palliative and End of Life Care Bundle has been adapted by kind permission of Prof. Sally Lawton. Roxburghe House, Aberdeen and NHS Grampian. The care bundle has been constructed in a manner which: Assists health, social care and care home staff to provide quality palliative care to people, no matter their diagnosis or location. Promotes advance and anticipatory care planning and the development of individualised care so that practitioners and their teams can work with people and those close to them to set and achieve common goals. Provides a framework that can be used with existing documentation. THE ADVANCE AND ANTICIPATORY CARE PLANNING (ACP) TOOLKIT http://www.palliativecareinpractice.nes.scot.nhs.uk/advance-anticipatory-care-planning-toolkit/ introduction.aspx DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION http://www.gov.scot/topics/health/quality-improvement-performance/peolc/dnacpr SCOTTISH PALLIATIVE CARE GUIDELINES http://www.palliativecareguidelines.scot.nhs.uk/ PALLIATIVE AND END OF LIFE CARE THE SCOTTISH GOVERNMENT http://www.gov.scot/topics/health/quality-improvement-performance/peolc/sfa Dundee Palliative Care Tool Bundle Supportive and Palliative Indicator Tool (SPICT) Palliative Performance Score (PPS) Response Standards NHS Tayside Anticipatory Care Plan NHS Scotland DNACPR form NHS Tayside Just in Case medication NHS Scotland Palliative Care guidelines Page 2 Page 11
Intensive level of Care People with Palliative Care Needs */ at end of Life PPS 30% or less The key standards for this Palliative and End of Life Care Bundle are: Community Nursing KEY WORKER: Senior Nurse in Charge can be deputised by another registered nurse from the core team. CONTACT: DAILY ASSESSMENT by a registered nurse from the core team minimum standard unless stated otherwise by the person. INITIAL RESPONSE TIME: from notification of the person at home, or discharge from hospital visit within 4 hours unless the person states otherwise The person is offered an initial assessment of performance and symptom status when it is recognised that they have palliative care needs. The person's care plan reflects their palliative and supportive needs. A regular review of the person's performance, symptom status and care needs is undertaken and recorded. Potentially reversible causes of decline are identified and treated, if appropriate. Care Home KEY WORKER Named Nurse / Senior Carer can be deputised by another member of the core team DAILY ASSESSMENT minimum standard unless the Person stabilises at this level weekly assessment Standard 1: The person is offered an initial assessment of performance status when it is recognised that they are have palliative care needs. The Supportive & Palliative care Indicators Tool (SPICT ) is used to aid in the identification of the person who has advanced, serious illness and acts as a trigger to consider assessment for identifying unmet palliative care needs. The Palliative Performance Scale (PPS) is recommended to be used to assess performance status. It is simple, quick to use and reproducible. Standard 2: The person's care plan reflects their palliative care needs. The care plan will reflect the identified physical, psychological, spiritual and social needs. Standard 3: A regular review is undertaken and recorded of the person's performance and symptom status. The care needs of both the person and their carer (s) should be considered. This standard can be achieved using the PPS, nursing response standards and NHS Scotland Palliative Care Guidelines to assess symptom control, recording any changes. Clinical judgement should guide the timing of discussions with the person and family/carers about their understanding of their situation and their care preferences. This will inform the Anticipatory Care Plan (ACP) which will enable subsequent completion of electronic information sharing, Key Information Summary (KIS) and DNACPR consideration. Standard 4: Potentially reversible causes of decline are identified and treated. NHS Scotland Palliative Care Guidelines can be used to identify the person's symptoms/ problems and to help make decisions about appropriate interventions. Discuss and report to GP. Standard 5: In situations where there are irreversible causes of decline, these are confirmed, clearly recorded and appropriate comfort measures put in place. The NHS Scotland, Scottish Palliative Care Guidelines can be used to guide comfort care at end of life. NHS Tayside Anticipatory Prescribing for Just in case Medication http://www.palliativecareguidelines.scot.nhs.uk/ Once the person has died, a review of the integrated care plan can be undertaken according to the 5 Standards Page 10 Page 3
Identify using SPICT Intermediate Level of Care People with Palliative Care Needs PPS 60 40 % Community Nursing KEY WORKER: Senior Nurse in Charge can be deputised by another registered nurse from the core team. CONTACT: WEEKLY ASSESSMENT by a registered nurse from the core team minimum standard unless stated otherwise by the person. INITIAL RESPONSE TIME: from notification of the person at home, or discharge from hospital 24 hours to make contact, visit within 48 hours unless the person states otherwise Care Home KEY WORKER Named Nurse / Senior Carer can be deputised by another member of the core team WEEKLY ASSESSMENT or sooner if sudden deterioration takes place Page 4 Page 9
Supportive Level of Care People with Palliative Care Needs PPS 70% or greater Community Nursing KEY WORKER: Senior Nurse in Charge can be deputised by another registered nurse from the core team. CONTACT: MONTHLY ASSESSMENT by a registered nurse from the core team unless stated otherwise by the person, or sooner if there is sudden deterioration. INITIAL RESPONSE TIME: from notification of the person at home, or discharge from hospital 48 hours to make contact, visit within a week unless the person states otherwise Care Home KEY WORKER Named Nurse / Senior Carer can be deputised by another member of the core team Page 8 Page 5
Assess using PPS Page 6 Page 7