Download Advanced Care Planning – Clinical Treatment Plan

Dorset adapted Proactive Elderly Advanced CarE (PEACE)
Suggested anticipatory care plan for care home residents
approaching end of life. Based on PEACE from GSTT.
This form is advisory only and may not be applicable if the resident’s wishes or clinical condition changes or
a situation arises which is not anticipated. If concerns please contact the named Physician or GP for further
advice
Resident’s
name
DOB
Hosp Number
Care Home
Physician
Tel no
Nurse
Tel no
Discharging
Hospital /
Ward
Date:
Summary of medical problems.
Resident’s views
Does the resident have mental capacity to decide about the actions in the event of progression of
their illness?
Yes / No
If yes, has this Suggested Action Plan been discussed and agreed with the resident?
Yes / No
Does this person have an: LPA?
ADRT?
Court Deputy?
Possible Developments specific
to the resident
1 Lower respiratory tract
infection/UTI
2 Fall and limb pain
3 Poor oral intake
4 Signs of possible stroke or coma
5 Person has no signs of life
6 Unexpected acute medical
problem/deterioration
Action
Category
Yes / No
Yes / No
Yes / No
details:
Comments
Please also see supplementary notes for
care home staff (attached)
Proactive Elderly Advanced CarE (PEACE)
SUGGESTED ACTION on PROGRESSION of ILLNESS
Resident’s
name
DOB
Hosp Number
Care Home
Physician
Date:
Nurse
Discharging
Hospital /
Ward
Summary of suggested action categories:
Intensive : Transfer to hospital for treatment if appropriate. Critical care, intubation and
ventilation should be considered.
Hospital : Transfer to hospital for treatment if appropriate but not for critical care, intubation
and ventilation.
Home : Treatment medication and comfort measures within care home with support from GP.
Admission to hospital to be avoided unless comfort measures fail.
Comfort : Palliative Medication by subcutaneous, oral or per rectal route, positioning, wound
care and other measures to relieve suffering. Implementation of Liverpool care pathway if
appropriate. Admission to hospital to be avoided unless comfort measures fail.
Views of significant others
The patient’s next of kin or advocate have / have not been consulted about this advice?
Summary of discussion / views of significant others including if there are differing opinions (which
may be relevant to future best interest decisions.)
Names
Relationship
Agree with above?
Yes/ No/ Not
involved
To be contacted?
Phone
Yes/ No/ Not
involved
Yes/ No/ Not
involved
Spiritual needs of the patient at the end of life:
Any other Comments
This form has been given to: (Please circle)
Patient
Relative
Care Home
Suggested review date:
GP
/
OOHS
/
ED
Proactive Elderly Advanced CarE : Guidance for care home staff
If your patient deteriorates and has a suggested action of ‘intensive’ or ‘hospital’ treatment, then
the appropriate action is to ring the GP/OOHS and if necessary arrange admission to hospital.
If your patient deteriorates and has a suggested action of ‘comfort’ or ‘home’, you may find the
following grids helpful. In order to carry them out, you may need to ask the GP to come to see the
patient and to prescribe as appropriate, and involve PICS or the palliative care service. Please
contact the patient’s significant others as stated on the front of this form.
Home
Oral food as tolerated (eg pureed).
If
required involve community SALT
Oral fluid as tolerated. If required follow SALT
advice. Where possible / appropriate you
may use sub-cutaneous fluids in the care
home.
Contact GP for diagnosis and treatment with
antibiotics if required.
If new pain GP may need to consider the
diagnosis, and treat accordingly
Feeding
Hydration
Infection
Pain
Breathlessness
Agitation
Nausea/vomiting
Diarrhoea
Drowsiness/
confusion
Fall
GP will need to consider cause of
breathlessness
and
what
treatment
medications are appropriate
Ensure no urinary retention/ constipation/
pain or other unmet need
If necessary call GP to prescribe sub cut
midazolam
Check no constipation / urinary infection and
treat accordingly + antiemetics
Check not overflow constipation (PR). Stool
samples for c.diff and treatment if positive.
Encourage fluids. Loperamide only if
continues for more than 3 days and risk of
skin breakdown
Check no constipation / urinary infection /
dehydration. Consider medications which
could be causing this. The GP may need to
do blood tests to guide therapy.
Examine for injury. If fracture suspected may
require admission to hospital for adequate
palliative management. Give analgesia prior
to transfer.
If no injury, consider cause of fall. Consider
need for crash mats, low bed, increased
supervision and assistance with toileting and
transfers.
Medications
Pressure
care
area
Pressure area care is based on risk
assessment and is fully documented. Patient
repositioning should be maintained ensuring
that pain issues are also addressed.
Pressure sores managed at home with review
by TVN and GP
Comfort
Oral fluids or food as tolerated
Oral fluids or food as tolerated and as often as
tolerated. Low intake is very likely
Treat symptoms as required. Fan therapy for
temperatures.
Call GP/Palliative care to consider medication
– oromorph or sub-cut morphine may be
required
Call GP/Palliative care to consider medication
– eg oromorph or sub-cut morphine. Consider
oxygen, normal saline nebulisers
Ensure no urinary retention/ constipation/ pain
or other unmet need
If necessary call GP to prescribe sub cut
midazolam
Check no constipation. GP will need to
prescribe anti-emetics, eg cyclizine oral or s/c
Check not overflow constipation (PR). Stool
samples for c.diff and treatment if positive.
Encourage fluids. Loperamide only if
continues for more than 3 days and risk of
skin breakdown
Check no constipation / urinary infection /
dehydration.
Consider medications which
could be causing this.
Examine for injury. If fracture suspected may
require admission to hospital for adequate
palliative management. Give analgesia prior
to transfer.
If no injury, consider cause of fall. Consider
need for crash mats, low bed.
Ask GP/Palliative care to review medications
– especially to stop unnecessary medications.
Pressure area care is based on risk
assessment and is fully documented. Patient
repositioning should be maintained ensuring
that pain issues are also addressed.
Pressure sores managed at home with review
by TVN and GP
In addition, pressure care, mouth care, management of continence issues, and spiritual wellbeing
will all be important.