Beechdale Health Centre

End of Life Policy, Audit, Patient Charter and Advance Care Plan

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A.Confidentiality Notice

This document and the information contained therein is the property of Beechdale Health Centre.

This document contains information that is privileged, confidential or otherwise protected from disclosure. It must not be used by, or its contents reproduced or otherwise copied or disclosed without the prior consent in writing from Beechdale Health Centre.

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Organisation: / Beechdale Health Centre
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C.Document Revision and Approval History

Version / Date / Version Created By: / Version Approved By: / Comments

CONTENT:

Page 3-Introduction

Page 3-Responsibility

Page 3-Policy

Pages 5 & 6 -Appendix A - End of Life Audit End of Life Review Summary Templates

Page 7-Appendix B - End of Life Care Patient Charter

Pages8 13-Appendix C - Advance Care Plan

Introduction

Caring for patients approaching the end of their life is one of the most important and rewarding areas of care. Although it is challenging and emotionally demanding, if staff have the necessary knowledge, skills and attitudes, it can also be immensely rewarding.

Responsibility

Beechdale Health Centre has a lead person responsible for End of Life Care and this is Mrs I Sharma

The End of Life Care Lead has undertaken an approved training course within the preceding 12 months that includes end of life tools, prognostic indicators for end of life, advanced care planning including advanced decision and “Do Not Attempt Resuscitation” (DNAR), review Liverpool Care Pathway (LCP) and drug packs.

Policy

All people approaching the end of their life need to have their needs assessed, their wishes and preferences discussed and an agreed set of actions reflecting the choices they make about their care recorded in a care plan.

In some cases people may want to make an advance decision to refuse treatment in case they lack capacity to make such a decision in the future.

Others may want to set out more general wishes and preferences about how they are cared for and where they would wish to die. These should all be incorporated into the care plan.

The care plan should be subject to review by the multidisciplinary team, the patient and carers as and when a person’s condition, or wishes, change.

For greater effectiveness, the care plan should be available to all who have a legitimate reason to access it (e.g. out-of-hours and emergency services).

Involving Family Members and Carers

The family, including children, close friends and informal carers of people approaching the end of their life have a vital role in the provision of care. They need to be closely involved in decision making, with the recognition that they also have their own needs.

For many people, this will have been the first time they have cared for someone who is dying.

They will require information about the likely progress of the person’s condition and information about services which are available.

They may well also need practical and emotional support both during the person’s life and after the point of death.

Carers already have the right to have their own needs assessed and reviewed and to have a carer’s care

Audit and Review

The Practice End of Life Care Lead will arrange to hold multi-disciplinary team meetings to cascade information and to review end of life/palliative care registers using the prognostic indicators.

The Practice End of Life Care Lead will also conduct quarterly reviews of all deaths of end of life patients from the Practice list.

Reviews will comprise the following:

Review palliative care patients with District Nursing team

Ensure palliative care folder is maintained

Review medication and palliative care arrangements

Reporting the Death of a Patient to the CQC

The Practice is required to notify the CQC without delay of the death of a patient when:

a)The death occurred whilst a regulated activity was actually being carried out (e.g. during a GP's home visit, or during the patient’s visit to your surgery),

OR

b)The death occurred as a result of a regulated activity being carried out,

AND

The Patient had seen their GP in the two weeks before the death,

AND

The death was avoidable / related to inappropriate care and treatment.

There is a dedicated notification form to report such deaths – it is contained in the Outcome 18 document “Notification of Death - Outcome 18 Composite Statement and Form”.

It is the responsibility of the Clinical member of staff to report it to CQC or the palliative care lead to do so,

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Appendix A

Beechdale Health Centre-End of Life Audit Template
Date of Death / Patient Name / Place of Death / Cause of Death / On Palliative Care Register? / Notes
End of Life Review Summary Template
Date of Practice Meeting:
Numerator / Denominator / Percentage
Hospital / %
Patient’s home / %
Residential home / %
Hospice / %
Community hospital / %
On palliative care register / %
Preferred place of death / %
Summary Notes of Meeting

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Beechdale Health Centre
End of Life Care Patient Charter
A charter for the care of people who are nearing the end of their life
“You matter because you are you; you matter to the last moment of your life
and we will do all we can, not only to let you die peacefully,
but to help you live until you die.” Dame Cicely Saunders
We want to offer people who are nearing the end of their life the highest quality of care and support. We wish to help you live as well as you can, for as long as you can. Therefore, if and when you want us to, we will:
  • Listen to your wishes about the remainder of your life, including your final days and hours, answer as best we can any questions that you have and provide you with the information that you feel you need;
  • Help you think ahead so as to identify the choices that you may face, assist you to record your decisions and do our best to ensure that your wishes are fulfilled, wherever possible, by all those who offer you care and support;
  • Talk with you and the people who are important to you about your future needs. We will do this as often as you feel the need, so that you can all understand and prepare for everything that is likely to happen;
  • Endeavour to ensure clear written communication of your needs and wishes to those who offer you care and support both within and outside of our surgery hours;
  • Do our utmost to ensure that your remaining days and nights are as comfortable as possible, and that you receive all the particular specialist care and emotional and spiritual support that you need;
  • Do all we can to help you preserve your independence, dignity and sense of personal control throughout the course of your illness;
  • Support the people who are important to you, both as you approach the end of your life and during their bereavement.
We also invite your ideas and suggestions as to how we can improve the care and support that we deliver to you, the people who are important to you and others in similar situations.

This charter has been developed by RCGP English End of Life Working Group,

Patient Partnership Group and RoyalCollege of Nursing (2011)

Advance Care Plan

(Planning my Future Care)

As individuals we may wish to put-in-place a record of what is important to us so that if we experience ill-health or an unforeseen event, like an accident, and become unable to make decisions we can be reassured by knowing we have already made clear our preferences.

This will help your family, carers, friends and professionals to discuss your future care with you.

None of us can identify exactly how our life will progress and how our end of life will look. Designing this plan gives you the opportunity to start these conversations, make your decisions or at least make your preferences known and clearly noted.

We have designed a draft plan that we hope you will find useful. Please feel free to amend it to suit your requirements. You may like to add photos to your plan.

This plan is not a legal document, but should you chose to use it please keep it safe so people can refer to it should the need arise.

You may find it useful (if you haven’t already done so) to have a file of important papers. While you may know exactly where to put your hands on them, your family may have the distress of searching through drawers when they need to find important papers quickly.

There are several documents that people, even in excellent health may wish to consider, to ensure they are discussed, actions taken and then left until such a time as they are needed. We hope this plan will act as a top sheet for your important information file.

We have included details suggested by carers who have had the experience of a death in the family and struggled to locate important information.

If you are worried about your memory you might find it useful to complete “this is me” a leaflet that gives greater detail about your likes and dislikes, in case you need to go to somewhere unfamiliar such as hospital.

If you need help with any of these documents then speak to your health or social care advisor or contact the Citizens Advice Bureau or Age UK who may be able to help.

Please keep this document in a safe place with other relevant documents. Remember to review it on a regular basis.

Tell the people you trust where they can find it.

My Personal Details
My first name: / My religion / spiritual faith is:
Surname:
Maiden name: / My GP details are:
I prefer to be called:
Date of birth: / My solicitor’s details are:
Place of birth:
National Insurance number:
My NHS number: / Executor details:
My husband / wife / partner is called:
I live with:
My home address: / Job title and employer:
My phone number: / Accountant details:
My mobile number:
My e-mail address:
Who and What is Important to Me?
People who are important to me: / Places or things that are important to me
(e.g. this could be your home, items of furnitureor even places you have been on holidayand really enjoyed):
Pets who are important to me:
The way I live my life that is important to me.(e.g. this could be that you like to have everything tidy and in its own place, or personal – e.g. spiritual / religious preferences, or particular ideas for your hair / clothing):
My Future Care Preferences
Most people prefer to live in their own home for as long as possible, however it may be that you become too sick or unable to care for yourself. Do you have preferences you would like people to consider in this regard? (e.g. this could be a particular residential home or area you would like to live in): / What I don’t want to happen or prefer not
to happen (e.g. I would prefer not to die in
hospital, but in my own home):
Family / carer comments - things they would like to record either that have been discussed and agreed or that you still are considering:
Is There Anything Else You Would Like Anyone Reading This To Know?
My Important Papers
Please record if you have the following documents: / Yes / No
Organ Donor Card
End of Life Preferred Priorities of Care (available through end-of-life healthcare professionals)
Advance Decisions to Refuse Treatment (seefor more information)
Do not attempt Cardio Pulmonary Resuscitation Form
Lasting Power of Attorney – 2 types:
1) Property and Financial Affairs
2) Health and Welfare
Both are legal documents. They don’t specifically have to be drawn up by a solicitor, but LPAs must be registered with the Office of the Public Guardian (see)
Funeral Plans
Please try to keep these documents all together,
so that it’s easy for anyone trying to track things down for you.
Tell people you trustwhere they can find these documents.
Family Members / Informal Carers
Name / Relationship to me / Phone
number / Do they hold a
copy of your plan?
(Y / N) / Next of Kin
(Y / N)
Any Professionals Involved
(e.g. Social Care Practitioner / Nurse)
Name / Role / Organisation / Phone
number / Do they hold a copy of your plan?
(Y / N)
Signed By
Your name:
Witnessed by:
Date:

This plan was developed by Lincolnshire County Council

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