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)
Link to Medical Goals of care Remuneration for palliative care provision in primary careDetermine goals of care & instigate holistic care plan
Consider completing NSW Ambulance Authorised Care plan as part of GPMP:
NSW Ambulance Fact Sheets*Communicate with patient and carer
- communicate using the PREPARED Model
- Starting Palliative Care Conversations Fact Sheet
- Video Ten steps for What to Say & Do
*provide the 'palliative approach' information link or leaflet to palliative care patients, carers and family members
- PalliativeCare_Booklet_2020_NSW_Digital.pdf (palliativecarensw.org.au)
- Talking about your symptoms (SAS )Flyer
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
Patient/carer holistic needs assessment (including physical, psychological, emotional, social, spiritual and cultural domains)
Link to Medical Goals of care Remuneration for palliative care provision in primary careDetermine goals of care & instigate holistic care plan
Consider completing NSW Ambulance Authorised Care plan as part of GPMP:
NSW Ambulance Fact SheetsKey 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
- Link to Remuneration for palliative care provision in primary care
*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
SPICT, SPICT4ALL, Symptom Assessment Scale (SAS), RUG-ADL, AKPS, Assessment & clinical response Form
*Care Coordination/MDT approach
Preferred Place Of Death (PPD) confirmed
- Hospital referral process .. add links
-RACF - AN-ACC & referral process
Complete Palliative Care Status Form
Home- identify needs, supports & services
*Communicate with family
Key clinical processes: Assess, Plan, and Communicate.
- Care after death
- Communication
- Grief support- post diagnosis
- Bereavement Support
- MDT Communication and Reflection
- After Death Audit