An individualised person centred management plan has been agreed and communicated to the patient, relatives and carers. If the patient does not have the capacity the plan is discussed with the Welfare Power of Attorney or Guardian.
This plan should be reviewed and documented daily and must include evidence of:
- Open, honest, sensitive communication, addressing any worries or concerns highlighted by patient, relatives and carers.
- DNACPR discussion and presence of form in notes.
- Discussion around what is important to the patient including preferred place of cafe and death, tissue/organ donation. If home is preferred place of care refer to Guidance for Rapid Discharge at End of Life.
- Discussion about plan for fluids and nutrition including the importance of mouth care.
- Ongoing assessment and management of symptoms including potential Palliative care emergencies.
- Prescribed anticipatory/just in case medications for common symptoms at end of life (see box below). Contact Hospital Palliative Care Team or Pharmacist for advice if required.
- Rationalisation/discontinuation of unnecessary medical, nursing and drug interventions.
- Confirmation of Death (CoD) paperwork is available where appropriate.
Review, update and communicate any changes with patient, relatives and carers at least once a day.