End of Life Advanced Care Planning

Claim Form

Read code: Patient Held Palliative Care Record

Practice Name
Reference Do not include any patient identifiable information, including NHS number
Residential Care/Nursing Home Address (if applicable)
Medical Condition/s
(Please tick) / Cancer [ ]
Chronic Condition [ ]
Dementia/Frailty [ ]
Choice of place of death
Note: this is captured at the time of completing this form and is subject to change
· GP discussed end of life issues with Residential Care/Nursing Home MDT meeting (if applicable) [ ]
· GP discussed resuscitation status, end of life issues, and place of care/death with patient/family/carers [ ]
· End of life plan completed & yellow folder in place Date:
· EoE DNACPR form completed (if applicable) Date:
(and faxed to 01234 215399)
· Harmoni OOH form/Special Patient Notes completed (via Adastra) if applicable [ ]
· End of life drugs package arranged (if applicable)
(Please see reverse of form and note this is an aide memoir only and is to help GPs and will not necessarily be needed) [ ]
· Patient added to practice palliative care register (if applicable) Date:
· Patient added to electronic palliative care coordinating system (EPCCS)
when available (if applicable) Date:

Useful Contacts

Admission Prevention Service / 01473 704259 / One Call / 0800 567011 or;
OOH / 0300 130 3066 / www.stelizabethhospice.org.uk
Please return completed claim form for the attention of Emily Thurston at Rushbrook House, Paper Mill Lane, Ipswich, IP8 4DE for payment purposes
“JUST IN CASE” DRUGS – LIST FOR END OF LIFE
Diamorphine
Haloperidol
Levomepromazine
Midazolam
Hyoscine Butyl Bromide
Water for Injection / 5 MG x 5 AMPS
5 MG/ML 5 AMPS
25 MG/ 5 ML 5 AMPS
10 MG / 2 ML 5 AMPS
20 MG / MP 5 AMPS
10 ML 10 AMPS / *(CD)
*(CD)

To access theDNACPR (Do Not Attempt Cardiopulmonary Resuscitation) documents, go to:
www.suffolk.nhs.uk/palliativecare

To access the e-learning programme:

·  Go to www.eoe.nhs.uk

·  Scroll down the left hand side to a purple box called “Changing OurNHS Together”

·  Select work stream “End of Life Care” and click “GO”

·  Select “DNACPR” in the left column where all the documents can be found

·  The documents that can be found on the webpage are:DNACPR Form & flowchart,DNACPR Patient Leaflet,DNACPR East of England Policy & Frequently Asked Questions sheet

·  At the bottom of this page is a link to access the e-learning programme

·  NB-You may have to register withEOE to access the e-learning programme. On completion of the training a certificate can be printed off for each staff member