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Key clinical processes: Assess, Plan, and Communicate.
- Identify patients at risk of deteriorating or dying
- Goals of Care
- Holistic MDT assessment and Care Plan
- Communication
- Advance Care Planning
- Symptom Management
- Carer Support
- Equipment provision
- For Patients with complex needs- Referrals to palliative care
Patient/carer holistic needs assessment (including physical, psychological, emotional, social, spiritual and cultural domains):
Determine goals of care & instigate holistic care plan:
- Consider completing NSW Ambulance Authorised Care plan as part of GPMP
- NSW Ambulance Fact Sheets
Clinical Assessment Tools:
Communicate with patient and carer:
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communicate using the PREPARED Model
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Ten steps for What to Say and Do (video)
Provide the 'Palliative Approach' information link or leaflet to palliative care patients, carers and family members:
Initiate Advance Care Planning discussion and complete documentation, if appropriate (including Advance Care Directive (ACD)
Refer to ACP toolkit as a guidance tool
Identify surrogate decision maker (SDM)
Initiate resuscitation discussion, if appropriate
Engage with all MDT members to provide quality symptom management.
Optimise symptom management
- Medical Goals of care (link to be added)
- Remuneration for palliative care provision in primary care
- Symptom Assessment Tools
- Illawarra Shoalhaven HealthPathways | ACT and SNSW HealthPathways
Rationalise regular medications.
- Consider Home Medication Review
Consider alternative consultation OPTIONS when patient is unable to attend the practice.
- Home visits, Virtual care consultations (VCC), Telehealth (Video).
Communicate with carer
Assess Carer needs, ask the carer to complete one of the following tools:
- NAT-C where the person you care for has cancer
- NAT-CC where they have a chronic condition
- Symptom Assessment Scale (SAS) to assess carer burden
Identify needs & supports, offer information, refer to other supports & services as required
- Provide carer booklet
- Provide information on carer supports - Illawarra Shoalhaven Southern NSW local support | SNSW local support
- Standard resources for carers and families
Consider referral to Carer Gateway or My Aged Care.
Communicate with carer:
Is a home and mobility assessment required?
- Refer to Allied Health for assessment via GPMP/TCA or LHD
- Palliative Care Equipment Loans and Purchases ISLHD | SNSW
Refer to My Aged Care.
Communicate with patient and carer.
Discuss with patient Preferred Place of Care (PCC).
- Caring@Home resources and training for carer/family (if home is PCC).
- Consider referral for grief counselling.
Palliative Care After Hours Helpline (Healthdirect Helpline) 1800 022 222.
Key clinical processes: Assess, Plan, and Communicate.
- Holistic MDT assessment and Care Plan
- Care Coordination/MDT Case Conferencing
- Communication
- Advance Care Planning
- Symptom Management
- Carer Support
- Equipment provision
- For Patients with complex needs - referrals to palliative care
Reassess holistic care needs frequently
- Medical Goals of Care (if included).
- Remuneration for palliative care provision in primary care
Review goals of care & care plan to address current and future anticipated needs
- Include limitations of medical treatment after episiodes of acute deterioration
Consider including General Practice Palliative Management Plan
- General Practice Palliative Management Plan template (currently under development with INCA).
Clinical Assessment Tools
Care Coordination and liaison across MDT settings
MDT Case Conferencing.
Communicate with patient and carer:
- Communicate using the PREPARED Model.
- Starting Palliative Care Conversations fact sheet.
Preferred Place Of Death (PPD) confirmed:
- Hospital referral process.
- RACF AN-ACC & referral process.
Complete Palliative Care Status Form.
Home - identify needs, supports & services.
Review and update Advance Care Plan / Advance Care Directive.
Review and update goals of care.
Confirm Preferred Place of Care (PPC) and consider transfer to PPC, if appropriate.
- If a Home is PPC use GP checklist Helping patients and families plan for an expected home death
- PPC - Hospital referral process
- RACF - AN-ACC & referral process
- Home- identify needs, supports & services
Initiate or review resuscitation discussion.
Complete Resuscitation plan, if not already done.
Complete Ambulance plan, if not already done.
Complete Medical Certificate Cause of Death (MCCD) for Expected Home Death, if at home.
Optimise symptom management.
Rationalise regular medications (Medication review & deprescribe as appropriate).
Prescribe anticipatory crisis drugs and orders.
Ensure drug administration equipment and charts are in place.
- Symptom Control in Palliative Care
- Medications in Palliative Care - Community HealthPathways Illawarra Shoalhaven
- Anticipatory Prescribing recommendations
Initiate carer assessment or reassess carer needs
- NAT-C where the person you care for has cancer
- NAT-CC where they have a chronic condition
- Symptom Assessment Scale (SAS) to assess carer burden
Identify needs & supports, offer information, refer to other supports & services as required
- Provide Carer Booklet
- Caring@Home resources and training for carer/family (if home is PCC)
- Information for patients and families
- Provide information on carer supports - Illawarra Shoalhaven Southern NSW local support | SNSW local support.
Carer respite - consider referral to Carer Gateway or My Aged Care.
Palliative Care NSW When to refer Flowchart
Refer to Palliative Care Team or Symptom Management Clinic
- Palliative Care Referral via HP
Care Coordination/MDT Shared Care meetings
Provide information on 24/7 palliative care helpline
- PCNSW | Welcome to Palliative Care NSW
- Palliative Care After Hours Helpline (Healthdirect Helpline) 1800 022 222
Consider referral to LHD for EoL package support
Key clinical processes: Assess, Plan, and Communicate.
- Holistic MDT assessment and Care Plan
- Communication
- Provide care in line with advance care plan
- Symptom Management in the last days of life
- Carer Support
- Equipment provision
- For Patients with complex needs- Referrals to palliative care
Reassess care needs daily
Review care plan, in line with goals of care, if appropriate
Commence End of Life pathway
- RACF consider RACF End of Life Care pathway
- Home GP checklist - helping patients and families plan for an expected home death
Clinical Assessment Tools
Care Coordination/MDT approach
Preferred Place Of Death (PPD) confirmed
- Hospital referral process
- RACF AN-ACC & referral process
Complete Palliative Care Status Form
Home- identify needs, supports & services
Communicate with family
Review ACP if appropriate
Consider transfer if appropriate to PPD
- If a Home is PPC use GP checklist - helping patients and families plan for an expected home death.
Initiate or review resuscitation discussion
Complete Resuscitation Plan, if not already done
Complete Ambulance Plan, if not already done
Complete Medical Certificate Cause of Death (MCCD) for Expected Home Death, if at home
Provision of culturally appropriate terminal care
Optimise symptom management.
Discontinue non-essential medications.
Prescribe anticipatory crisis drugs and orders.
Ensure drug administration equipment and charts are in place.
PCA the Dying process - information for carers.
Refer to home care services, if required.
Provide carer medical certificates, if needed.
Identify carers ‘at risk’ of bereavement.
At the end factsheet, video and resources for patients and carers.
Referral for Provision of aids & equipment ISLHD Equipment Loan Pool | SNSW Equipment Loan.
Refer to allied health team, if required.
Refer to LHD for End of Life package supports if required.
Home Care Package supports.
Consider referral to LHD for EoL package support:
If death occurred as a result of the administration of a VAD substance, the usual guidelines for non-reportable deaths apply, with the additional requirements that the MCCD must:
- record that the patient self-administered or was administered a voluntary assisted dying substance, and
- record the underlying medical condition that made the patient eligible for voluntary assisted dying.
Section 19.4: Notification of Death from the NSW Voluntary Assisted Dying Clinical Practice Handbook.
Key clinical processes: Assess, Plan, and Communicate.
- Care after death
- Communication
- Grief support- post diagnosis
- Bereavement Support
- MDT Communication and Reflection
- After Death Audit
Legal documents for completion (as needed)
Undertake verification of death
Complete Coroners checklist
Complete medical certificate cause of death
Completed Attending Practitioner’s Cremation certificate if required
Communicate with family & carers
Provide bereavement information to carer & family members
After Death information
Information about Grief and Bereavement
- ISLHD & SNSWLHD Palliative Care Bereavement Services
- Bereavement Support – Grief Australia
- A practical guide to coping with bereavement
- NSW Grief & Bereavement Services
- Griefline Integrating Grief Program
- Information about Financial Support
After Death Audit
After Death audit quality improvement tool
Self Care