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1Priorities of Care 30 April 2015 Version 2
‘Priorities of Care’Individualised Care Plan
Patient’s name
NHS number
Senior clinician
Registered nurse/Key worker responsible for care
Key worker contact number
Out of hours telephone number
Priorities for care
1. 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 person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.
2. Sensitive communication takes place between staff and the person who is dying, and those identifi ed as important to them.
3. The dying person, and those identifi ed as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.
4. The needs of families and others identifi ed as important to the dying person are actively explored, respected and met as far as possible.
5. An individual plan of care, which includes food and drink, symptom control, psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.
Commencing this Care Plan is a multidisciplinary decision.Put the ‘information for Drs sheet’ in the Medical/Progress notes.
2 Priorities of Care 30 April 2015 Version 2
Professionals and Agencies Involved in the Patient’s Care
Patient’s name
Date of birth NHS number
Lasting Power of Attorney
Name Telephone number
Address Health & wellbeing Property & fi nance
Psychological and Bereavement Services
Name
Date referred Telephone number
Nurse Specialist/Nursing Services involved
Name Telephone number
Name Telephone number
Faith or Religious Support
Name of Chaplain/Vicar or Priest
Contact number
Care Agency
Name
Date referred Telephone number
Consent to share information
To assist with your care we may have to refer you to other healthcare professionals and share your information with them.
Please tick box if patient consents to this Patient agreed
Name of advocate Patient advocate agreed
3Priorities of Care 30 April 2015 Version 2
Patient Information
Patient’s name
Date of birth NHS number
Assessor sign Designation
Assessor print Date Time
Address/Addressograph Telephone
PostcodeMobile
GP name Telephone
Surgery
Diagnosis
Other relevant information
Allergies
Preferred place of care
Is there an advance care plan (ACP)? Yes No
Is there an Advance Decision To Refuse Treatment (ADTRT)? Yes No
Where is it held?
Cardiopulmonary Resuscitation Status (DNACPR) Yes No
Where is it held?
Religion/Faith
Family/Carer contact details1st contact
Family/Carer contact details2nd contact
Name Name
Relationship Relationship
Address Address
Contact number Contact number
Contact number 2 Contact number 2
Care in the community
Triage bypass card in place Yes No
Is an ACP/ADRT held on Adastra Yes No
Just in case medication in place Yes No
4 Priorities of Care 30 April 2015 Version 2
Record of Initial Discussion
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
• Record conversation with patient, their understanding of their diagnosis and prognosis.
• Record mental capacity at the time of the conversation.
• Identify if a Cardiopulmonary Resuscitation Decision has been made and if the patient was involved with this decision.
• Identify those present during the conversation.
• Record conversation with those close to the patient, their understanding of the diagnosis and prognosis.
• The level to which they wish to be involved in the patient’s care.
Record all subsequent conversations on the Record of Conversations.
5Priorities of Care 30 April 2015 Version 2
Baseline Nursing Assessment /Re-Assessment
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Communication
(Detail any barriers or needs, including sight or hearing loss)
Neural capacity assessment
Patient’s understanding of their condition/Including mental capacity
Detail fears or concerns
Family’s understanding of the patient’s condition
Detail fears or concerns
Psychological, emotional and spiritual needs
EatingIs clinically assisted nutrition required Yes No
MUST score
DrinkingIs clinically assisted hydration required Yes No
Bowel care
Urinary output
Describe urinary output Is catheter in situ? Yes No
Suprapubic or urethral Date last changed
Breathing
Mobility
(Please detail any moving or handling requirements)
Waterlow score
Skin careAre there any wounds/injury? Yes No
If Yes, detail wound care in care plan
6 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
7Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
8 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
9Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
10 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
11Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
12 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
13Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
14 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
15Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
16 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
17Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
18 Priorities of Care 30 April 2015 Version 2
Daily Nursing Assessment and Management of Symptoms
(Review 4 hourly if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
No Problem Summary of problems Signature
1 Pain
2 Nausea
3 Vomiting
4 Secretions
5 Dyspnoea
6 Urinary
7 Bowels
8 Skin care/Pressure areas
9 Eating
10 Drinking
11 Mouth care
12 Agitation
13Psychological, emotional, spiritual
14 Mental capacity
15 Other problem
19Priorities of Care 30 April 2015 Version 2
Daily Nursing Care Plan(Plan more frequently if needs are rapidly changing)
Patient’s name
Date of birth NHS number
Nurse sign Designation
Nurse print Date Time
Time Planned care/Care given
Please record all care planned including personal hygiene
Time Evaluation and key issues to take forward
Signature of evaluator Print
20 Priorities of Care 30 April 2015 Version 2
Additional Information
Patient’s name
Date of birth NHS number
Date/Time Please record repositioning/mouthcare/other care here Signature/Print/Designation
21Priorities of Care 30 April 2015 Version 2
Additional Information
Patient’s name
Date of birth NHS number
Date/Time Please record repositioning/mouthcare/other care here Signature/Print/Designation
22 Priorities of Care 30 April 2015 Version 2
Communication Sheet(Record all multidisciplinary decisions, conversations
with patients and relatives)
Patient’s name
Date of birth NHS number
Date Time Communication Signature/Print/Designation
23Priorities of Care 30 April 2015 Version 2
Communication Sheet(Record all multidisciplinary decisions, conversations
with patients and relatives)
Patient’s name
Date of birth NHS number
Date Time Communication Signature/Print/Designation
24 Priorities of Care 30 April 2015 Version 2
‘Priorities of Care’Individualised Care Plan
Information for doctors
For patients who are probably dying
• It is very hard to be certain that a person is dying. Sometimes it is reasonable to be giving basic ward treatments whilst also giving symptom control drugs.
• Communicate clearly with the family about the expected prognosis and any uncertainty and document your thoughts and the contents of any discussions. An example of what might be said is, “I think your father is dying but there is a small chance he may pull through. We’ll continue to try antibiotics at the moment but we will also aim to keep your father pain free with appropriate medications so that if he continues to deteriorate, he won’t suffer.”
• It is important to ensure that the following has been clearly documented in the appropriate place:
Advanced care plan/advanced decision to refuse treatment/do not resuscitate and ceilings of treatment decisions.
• Issues to consider include:
What PRN medications may be needed to relieve suffering? Write these up before they are needed.
How important is maintaining hydration at this stage? How important are longer term medications such as anti-hypertensives? How important is it to know the vital signs?
Is there an ICD in situ? If so, it will need deactivation.
What would be the best site of care for this patient?
After death occurs, will a post-mortem or referral to the Coroner be required? If so, it may be helpful to discuss this with the family early.
The patient’s previous occupation, time of death and people present at death will be needed to fi ll out paperwork after death.
• See the Isle of Wight’s Palliative Medicine Symptom Advice Guidelines for help. Hard copies can be obtained from the Earl Mountbatten Hospice, electronic copies can be downloaded from their website and mobile and tablet apps can be downloaded from the iOS, Android and Windows app stores.
• Please don’t hesitate to call the Island’s palliative care team for advice +/- a review if you feel this might help.
(Place this sheet in the medical/progress notes when commencing the Priorities of Care, Care Plan)
25Priorities of Care 30 April 2015 Version 2
‘Priorities of Care’Individualised Care Plan
Information for nurses
For patients who are probably dying
• Good nursing care will make a person’s death more peaceful and dignifi ed where the focus of care is on maintaining comfort and relieving suffering; this care will extend to family members who will be fi nding the time incredibly stressful, and time will be needed in caring for and communicating with the family too.
• It is helpful to communicate well with the medical staff about what they think the prognosis is and whether recording observations such as blood pressure are still needed.
• It is important to have recorded in the appropriate part of the case notes information related to:
Lasting power of attorney and next of kin and family members contact details.
• To minimise suffering, physical and symptom observations of most relevance are:
Pain
Nausea
Vomiting
Secretions
Dyspnoea
Urinary incontinence or retention
Bowel incontinence or constipation
Skin care and pressure areas
Oral intake and mouth care
Agitation
• Document in the medical/progress notes if any of the above are particularly concerning and, if required, speak to the treating medical team if PRN medications are not bringing relief.
• Document the contents of any discussions with family members in the medical/progress notes.
• Other issues to think about include:
Is there a role for a chaplain or input from other spiritual or religious leaders?
Is there a role for psychological or bereavement services?
• Please don’t hesitate to call the Island’s palliative care team for advice +/- a review if you feel this might help.
26 Priorities of Care 30 April 2015 Version 2
Care After Death
Patient’s name
Date of birth NHS number
For an expected death at home call 111.
Refer to policy for care after death, the management of patient’s property and the deactivation of ICDs.
Date of death
Certifi ed by
Referred to the Coroner Yes No Date
Tissue donation
Funeral arrangements
Burial Cremation
Chosen Funeral Director Telephone number
Family and carer needs
Name
Relationship
Contact details
Other needs
27Priorities of Care 30 April 2015 Version 2
Signature Sheet
Patient’s name
Date of birth NHS number
Please give your full name, designation, full signature and initials below if you write in this care plan.This is for legal purposes.
Full name (printed) Designation Full signature Initials
28 Priorities of Care 30 April 2015 Version 2
Photocopy these notes and retain photocopies in the records if patient is
transferred between hospital, hospice or home.