Day 1.  Housekeeping  Introductions  Ground rules

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QCF level 2 award

5 priorities of careDay 1WelcomeHousekeepingIntroductionsGround rules

Our viewsFactors which influence and impact on us

EmpathyHearing what THEY hearSeeing what THEY seeFeeling what THEY feel

Would you do it differently?History in relation to documentation

LCPBaroness Neuberger (July 2013)There is no doubt that, in the right hands, the Liverpool Care Pathway supports people to experience high quality and compassionate care in the last hours and days of their lifeHoweverBut evidence given to the review has revealed too many serious cases of unacceptable care where the LCP has been incorrectly implemented. Examples include leaving patients without adequate nutrition, hydration and inappropriately sedatedThis is not only awful for the patients, but it is deeply distressing to their relatives and carers. Bigger PictureWhat we have also exposed in this Review is a range of far wider, fundamental problems with care for the dying a lack of care and compassion,unavailability of suitably trained staff, no access to proper palliative care advice outside of 9-5 Monday to Friday.

Leaderships Alliance for the Care of Dying PeopleSet up to lead and provide a focus for improving the care for this group of people and their families and carers

Followed the publication of the More Care Less Pathway reportCare Quality Commission (CQC)NICE (National Institute for Health and Care Excellence)College of Health Care Chaplains (CHCC)NHS EnglandDepartment of Health (DH)NHS Trust Development Authority (NTDA)General Medical Council (GMC)NHS Improving Quality (NHS IQ)General Pharmaceutical CouncilNursing and Midwifery Council (NMC)Health and Care Professions Council (HCPC)Public Health England (PHE)Health Education England (HEE)Royal College of GPsMacmillan Cancer SupportRoyal College of Nursing (RCN)Marie Curie Cancer CareRoyal College of Physicians (RCP)National Institute for Health Research (NIHR)Sue Ryder CarePurposeDevelop advice for professionals on individual care plans and other arrangements in place of the Liverpool Care Pathway;

MappingLooking at existing guidance, training and development, then consider how these impact on the care of dying people and the circumstances that might affect the adoption of good practice

WorkshopsAs part of its work, a series of workshops is being held to share the alliances thinking around providing consistent, high quality care for dying people in their last days and hours of life and to involve and engage clinicians and the public, in helping to determine what the best way forward is.

The workshops will focus on the proposals for a set of desired outcomes for people who are dying which, supported by guiding principles for clinicians, should be the basis of care in different settings and circumstances

One chance to get it right5 priorities of care

The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the persons needs and wishes, and these are regularly reviewed and decisions revised accordingly.Recognise Sensitive communication takes place between staff and the dying person, and those identified as important to them.CommunicateThe dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.InvolveThe needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.SupportAn individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion.Plan and DoThe End of Life Care PathwayDiscussionsas the end of life approachesAssessment, care planning and reviewCoordination of care

Delivery of high quality services in different settings

Care in the last days of life

Care after deathOpen, honestcommunication Identifyingtriggers fordiscussionAgreed careplan andregular reviewof needs andpreferences Assessingneeds ofcarersStrategic coordination Co-ordinationof individualpatient care RapidresponseservicesHigh qualitycare provisionsin all settings Acutehospitals,community,care homes,extra carehousinghospices,communityhospitals,prisons, securehospitals andhostels Ambulanceservices.Identificationof the dyingphase Review ofneeds andpreferencesfor place ofdeath Support forboth patientand carer Recognitionof wishesregardingresuscitationand organdonation.Recognition thatend of life caredoes not stopat the point ofdeath Timelyverification andcertification ofdeath or referralto coroner Care and supportof carer andfamily, includingemotionaland practicalbereavementsupport202020Step 1Open honest communicationIdentifying triggers for discussionStep 2Agreed care plan & regular review of needs & preferencesAssessing needs of carersStep 3Strategic co-ordinationCo-ordination of individual patient careRapid response servicesStep 4High quality care provision in all settingsAcute hospitals, community, care homes, hospices, community hospitals, prisons, secure hospitals & hostelsAmbulance servicesStep 5Identification of the dying phaseReview of the needs & preferences for place of deathSupport for both patient & carerRecognition of wishes regarding resuscitation and organ donationStep 6Recognition that EOLC does not stop at point of deathTimely verification & certification of death or referral to coronerCare & support of carer & family including emotional & practical bereavement support

20Achieving priorities of carePrinciples of ACPAdvance statementAdvance decisionLasting power of attorney Funeral arrangementsAdvance care planning23One of the main principles is and it is important to be clearAdvance statementA requesting statement reflecting an individuals preferences and aspirationsFormalise what the patients and their family do wish to happen, allowing them to fill clearer in their own mindCan be useful to clinicians in planning of patients individual care knowing how a person would like to be treatedNot legally binding but can/should be used within best interest decisionsMay also need advanced decision and DNACPR24I would want to be clear what a statement was..Written on anything!

Decision making toolsPreferred Priorities of Care (PPC)Say it once: my advance care planThinking aheadMy VoiceThis is me.. Advanced decision from specific groups such as MNDEliciting preferences form

26Again, hoping to make it relaxed and open as possible would ask them what tools there are. Will have the PPC form to show them, the thinking ahead template and the eliciting preferences form and explain more statements than legally binding decisions as the ardtLPoA is important to acknowledge that a LPOA can make decisions on their behalf if they subsequently lose capacity. They may have been appointed to make specific instructions once capacity lose. An advanced decision is not valid if a LPOA has been created subsequently to the ARDTAdvance decisionAn advance decision must relate to a specific treatment and specific circumstancesFormalises what patients do not wish to happen giving them controlIt will only come into affect when capacity lostLegally binding documentRelated to capacity of decision making, mental capacity act27And more importantly what a decision was as it becomes a legally binding document

Lasting Power of Attorney

Check.Lasting power of attorney?In health and welfare?Can make decisions in life sustaining treatment?Is it registered with the office of the Public guardian?

They maybe a deputy under the court of protection if they do not have capacity to appoint a lasting power of attorney.They may have been appointed an agent by the department of work and pensions for bills etc.A lasting power of attorney (LPA) is a legal document that lets you (the donor) appoint one or more people (known as attorneys) to help you make decisions or make decisions on your behalf.

This gives you more control over what happens to you if, for example, you have an accident or an illness and cant make decisions at the time they need to be made (you lack mental capacity). Does not want CPRBe careful not to offer CPR as a treatment if not considered successful.You are only getting preferencesIf does not want CPR = ADRT or support process of uDNACPR with GP.UDNACPRPurple Form- Who completes it?- Who owns it?- Where it is stored?- Document in patients notesEnsure it is communicated to all that needs to know

31Who completes it? Completed by the most senior clinician, if this isnt the Consultant or GP, then it will need to be verified.Within organisations, there may be Senior experienced, appropriately trained nurses who are able to do this. Need to ensure that the organisation recognises this role, and provides indemnity for the individual.Who owns it?The form, and most importantly the decision belongs to the person, not the Institution. The form will travel with the person, ambulance crew instructions need to be completed.Where it is stored?The form is stored either in the front of persons notes, or in their home.See message in a bottle.Documentation in notesThe form being completed does not negate the need to document in the persons notes.

The decision1.ACPR is unlikely to be successfulClinician may fill would not benefit at all and could look at Elsies prognosis and situation as a 1A decision

1.BCPR may be successfulElsie has made it clear that she does not want CPR through ACP discussion so could be a 1b decision.

1.CDNACPR is in accord Elsie could have a 1c decision if he completes his ADRT.

32Quiz When could you consider starting an advance care planning conv


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