Individualised End of Life Care Plan for the Last Days or Hours of Life Patient name Hospital number Date of birth

Individualised End of Life Care Plan for the Last Days or Hours of Life Patient name Hospital number Date of birth NHS number Informed by Five Priorities for Care: Recognise, Communicate, Involve, Support, Plan and Care Consultant: Ward: Date: Following the initial patient assessment the Medical plan is discussed and agreed with nursing and allied healthcare staff, the patient (if has capacity) and with the patients family / carer and those important to them. Following a patient assessment and agreement that all reversible causes for current condition have been considered; the multi-professional team has agreed that the patient is dying. Name of doctor and nurse responsible for and completing the initial patient assessment Care Plan: Date: Time: Dr signature: GMC No: Grade: Nurse signature: Grade: All personnel completing this document, please sign below: Name of family member with whom care plan has been discussed (if not, why not?) Name (print) Signature Initials Designation Date Name.. Hosp No. Date..

Communication between clinical team and family/carer: Anyone can write their comments in the space below. It could be used to ask questions or request contact from the clinical team. Name.. Hosp No. Date.. Date Notes Name (designation or relationship) and contact details (e.g. mobile phone number)

The initial patient assessment should be completed as a joint assessment and signed by both the doctor and the nurse involved. The patient s care should be individualised to their specific needs. If advice is needed at any stage, contact a senior member of the team or Oakhaven Hospice on 01590 670346 Statement of health care practitioner: I confirm that recognition of dying has been discussed with the patient (where appropriate) and family/nok Family Contact Details If the patient s condition changes, who should be contacted first? If the patient s condition changes, when should they be contacted? If the first contact is unavailable, who should be contacted? When to contact Recognition that the Patient is Dying Consider reversible causes for the patient s deterioration. This decision should be made by the most senior clinicians (nurses and doctors) caring for the patient. 1 st contact: name: Relationship to patient: Telephone no: Mobile no: At any time:. Not at night time: Not between...and... 2 nd contact: name: Relationship to patient: Telephone no: Mobile no: At any time: Not at night time: Document whether reversible causes have been considered: Document who is involved in making the decision: Why do you consider the patient is dying? Take into account whether the patient is bedbound, unconscious, semi-conscious, unable to take more than sips of fluids, reduced peripheral perfusion, respiratory tract secretions etc. Sensitive Communication with the Patient and Family Remember to apply the principle of the Mental Capacity Act 2005 Consider if the patient has capacity to make Document the conversation, including all the issues covered decisions about their care. (use MDT communication sheet if needed): Explain to the patient/family/carer what is happening and the reasons why you think the person is dying... Discuss prognosis (and the difficulty making a.. time limited prognosis).. Discuss priorities for care, including place of care. if appropriate. Even very ill patients actively dying. may be discharged home. If they and their family wish is to go home facilitate rapid discharge... Give written information. Name.. Hosp No. Date..

Patient Preferences and Advance Decisions Does the patient have: Any previously expressed wishes? Yes No An advance care plan? Yes No Record actions to be taken. If required continue on the MDT communication sheet. An advance decision to refuse treatment (ADRT)? Yes No An expressed wish for organ/tissue donation? Yes No A lasting power of attorney for health and welfare? Yes No Consider all the investigations, interventions and treatments the Patient is having Stop investigations, interventions or treatments that will not promote comfort and dignity. Document what has been stopped and why use MDT communication sheet if required. Discuss with the patient and/or family. DNACPR status Discuss sensitively with the patient and family if appropriate. Document DNACPR on the appropriate form and on the MDT communication sheet. Review Current Interventions Review current medications Continue Discontinue N/A Prescribe as required s.c. medication for pain, agitation, nausea and vomiting, respiratory tract secretions and breathlessness Continue Commenced N/A Routine blood tests Continue Discontinue N/A Commenced Intravenous antibiotics Continue Discontinue N/A Commenced Blood glucose monitoring Continue Discontinue N/A Commenced Intravenous fluids Continue Discontinue N/A Commenced Subcutaneous fluids Continue Discontinue N/A Commenced Artificial nutrition Continue Discontinue N/A Commenced To be reviewed in line with daily needs Name.. Hosp No. Date..

Initial Care Plan Assessment PROMPTS FOR BEST CARE Prescribe JUST IN CASE DRUGS for common symptoms at the end of life (see local guidance) Does the patient require regular painkillers, anxiolytics, anti-sickness or anti-secretory drugs, if so prescribe a SYRINGE DRIVER Would referral to SPECIALIST PALLIATIVE CARE TEAM be helpful? Would the patient / any family members appreciate the support of a healthcare CHAPLAIN OR LOCAL FAITH LEADER? Can you adjust the PHYSICAL ENVIRONMENT to support the patient s needs e.g. screens, clean environment, sufficient space at bedside for family, silence, music, nurse call bell accessible Physical care needs - The consider list is not exhaustive and all elements of patient need should be assessed 1 Consciousness: Assess patient s current level of consciousness 2 Eating and drinking consider All patients who are able to take sips of fluid should be offered drinks Assistance required Ability to swallow Patient decision to eat and drink even if this presents a risk PEG/RIG/NG in situ Consider the possible benefits and burdens of artificial hydration and nutrition 3 Pain - consider Usual history and sites of pain Current pain levels, location, type and cause Provoking or exacerbating factors Comfort and relief measures including drug intervention and non-drug measure (e.g. position, heat pads, TENs) 4 Nausea and vomiting consider Cause and frequency Comfort and relief measures including drug intervention and non-drug measures (e.g.position, food, fresh air) Equipment and support required: (e.g. bowls, tissues, mouthwash) Physical / psychological / spiritual care needs The consider list is not exhaustive and all elements of patient need should be assessed 5 Breathing and respiratory care consider Presence of breathlessness, stridor or respiratory secretions Causes Drug interventions include oxygen (include method of delivery) Non drug interventions (e.g. position, fans, open windows) Assessment & Plan Assessment & Plan Name.. Hosp No. Date..

6 Other physical considerations: e.g. Fistula, Oedema 7 Psychological, emotional, spiritual and religious concerns consider Provide opportunity to discuss what is important to the patient and family, including feelings, beliefs, wishes and values. Offer support of Chaplaincy team. Identify any specific needs prior to, at, or following death. 8 Agitation, restlessness and hallucinations consider Assessment using a recognised tool Causes (e.g. urinary retention, constipation, pain) and exacerbating factors (e.g. noise, loneliness, family situation) Underlying causes (e.g. dementia, cognitive impairment, brain injury) Comfort & Personal Care The consider list is not exhaustive and all elements of patient need should be assessed 1 Washing, dressing and grooming Consider assistance required and normal routine 2 Skin care Braden score plus care plan if required Skin assessment and care plan if required Pressure relieving equipment required 3 Mouth care Current condition of mouth Assessment of risk and mouth care required Comfort and relief measures including drug intervention and non-drug measures 4 Bladder and bowels Consider patient mobility and normal toileting routine Equipment and assistance required Normal routine and current state Comfort and relief measures including drug intervention and non-drug measures 5 Mobility Mobility and moving and handling assessment Falls risk considered Equipment and assistance required 6 Sleeping consider Preferred place and position to sleep (e.g. bed, chair, sitting up) Ability to sleep and causes of poor sleeping Drug and non-drug interventions Assessment & Plan

Daily Ongoing Review Date:. Is the patient still thought to be dying? Yes No Continue overleaf Time of Review 04:00 08:00 12:00 16:00 18:00 20:00 24:00 Current Level of Consciousness C - Conscious, S - Semi Conscious, U - Unconscious Pain C the patient has remained COMFORTABLE. P the patient has experienced PAIN and has received appropriate nursing intervention and/or medication. Nausea and Vomiting C the patient has remained COMFORTABLE. N the patient has experienced NAUSEA and received appropriate nursing intervention and /or medication. V the patient has VOMITED and received appropriate nursing and /or medication to alleviate it. Agitation C the patient should be CALM and COMFORTABLE. A the patient has displayed signs of AGITATION and received appropriate nursing intervention and/or medication. Respiratory C the patient is COMFORTABLE with their breathing. B the patient has experienced BREATHLESSNESS and received appropriate nursing intervention and /or medication. S the patient has experienced respiratory tract SECRETIONS and received appropriate nursing intervention and/or medication. Mouth Care G Mouth care GIVEN. D Mouth care offered but DECLINED. Drink and Hydration Sips the patient has been assisted to have sips of fluid, as they can tolerate. patient has been assisted to drink. P The patient is too poorly to tolerate drink now. PEG/RIG The patient has received fluids via their feeding tube. E+D The

Time of Review 04:00 08:00 12:00 16:00 18:00 20:00 24:00 Food and drink E+D The patient has been assisted to eat. P The patient is too poorly to tolerate food now. PEG/RIG The patient has received nutrition via their feeding tube. Personal Care C the patient has RECEIVED PERSONAL CARE (eg washing, dressing, eye care, hair care) N the patient has NOT REQUIRED CARE. D the patient has DECLINED CARE. Pressure Area Care C the patient has remained COMFORTABLE and assisted to reposition, as necessary. R the patient s pressure areas have been reviewed and/or dressings RENEWED. If pressure ulcers present, document grade and consider appropriate mattress. Urinary Care PU PASSED URINE. NPU NOT PASSED URINE. Cath Urinary CATHETER in situ and is patent. U=Urostomy, N=Nephrostomy. Respiratory C the patient is COMFORTABLE with their breathing. B the patient has experienced BREATHLESSNESS and received appropriate nursing intervention and /or medication. S the patient has experienced respiratory tract SECRETIONS and received appropriate nursing intervention and/or medication. Bowel Care Document when bowels last opened.. BO BOWELS OPENED. BNO BOWELS NOT OPENED. Initials of assessor(s Shared with the family / carer Yes No N/A Time of Review 02:00 04:00 06:00 08:00 10:00 12:00 14:00 C psychological and spiritual verbal and non-verbal support has been offered and the PATIENT IS CALM, PEACEFUL AND FEELS WELL SUPPORTED. D the PATIENT IS EXPERIENCING PSYCHOLOGICAL AND / OR SPIRITUAL DISTRESS and has been offered additional support from the MDT eg chaplain or own faith leader. Care of Family / Carers C Psychological and spiritual verbal and non-verbal care and support has been offered, and the PATIENT S FAMILY/CARERS FEEL WELL SUPPORTED. D The patient s family / carers are experiencing psychological and /or spiritual DISTRESS and has been offered support from the MDT. Initials of assessor(s Shared with the family / carer Yes No N/A

Daily Ongoing Review Date:. Is the patient still thought to be dying? Yes No Time of Review 04:00 08:00 12:00 16:00 18:00 20:00 24:00 Current Level of Consciousness C - Conscious, S - Semi Conscious, U - Unconscious Pain C the patient has remained COMFORTABLE. P the patient has experienced PAIN and has received appropriate nursing intervention and/or medication. Nausea and Vomiting C the patient has remained COMFORTABLE. N the patient has experienced NAUSEA and received appropriate nursing intervention and /or medication. V the patient has VOMITED and received appropriate nursing and /or medication to alleviate it. Agitation C the patient should be CALM and COMFORTABLE. A the patient has displayed signs of AGITATION and received appropriate nursing intervention and/or medication. Respiratory C the patient is COMFORTABLE with their breathing. B the patient has experienced BREATHLESSNESS and received appropriate nursing intervention and /or medication. S the patient has experienced respiratory tract SECRETIONS and received appropriate nursing intervention and/or medication. Mouth Care G Mouth care GIVEN. D Mouth care offered but DECLINED. Drink and Hydration Sips the patient has been assisted to have sips of fluid, as they can tolerate. patient has been assisted to drink. P The patient is too poorly to tolerate drink now. PEG/RIG The patient has received fluids via their feeding tube. E+D The Continue overleaf

Multiprofessional clinical notes I summary of discussion Date and Time Notes Signature