Palliative Care Quality End Of Life Care Resource Book

Palliative Care Referral FormDownload this form TE ALL DETAILS OR AFFIX PATIENT LABEL HEREFamily NameGiven NameMRNSpecialist Palliative &Supportive Care ServiceReferral Form NorthReferral to:M.ODate of birthMaleFemaleAddressLocation / WardAttention:Palliative Care Inpatient UnitCommunity Palliative Care ServiceStaff Specialist (Greenwich)Staff Specialist (Neringah)Staff Specialist (Northern Beaches)Referrer’s NamePatient locationConsent to referral?Referrer’s Contact NumberPatientFamilyPerson responsibleReferral’s FacilityOn behalf of DoctorRelationshipTel NoName of Palliative Care ConsultantDoctor’s Provider NumberGP Name (if not referring doctor)Medicare NumberHealth Fund NamePractice NameLanguageNo.GP Phone NumberIs GP aware of referral?YesNoReason for referral (select one or more if applicable):Symptom controlTerminal careDiagnosis and treatment (previous & current):Lives alone?YesNoInterpreter needed?YesNoPsychosocial supportSupportive careMedical history:NSW Health Resuscitation Plan completed? (Please attach to this form)YesNoRelevant additional documents not available on eMR attachedYesNoN/AInfection status and location:Falls risk / behavioural concerns:Special instructions:(tracheostomy, wound care, CVADs, PEG, modified diet needs)Functional status:IndependentPartial assistSkin integrity:Full assistWaterlow score:Patient and family concerns:Understanding of disease:Goals of care:Spiritual / cultural needs:Referring Doctor’s Signature:Date:Rev:Please fax completed referral to:Greenwich Hospital – Inpatient Unit Tel: 9903 8227Fax: 9903 8100Neringah Hospital – Inpatient UnitTel: 9488 2200Fax: 9487 1599Palliative Care Community NorthTel: 1800 427 255 Fax: 9903 8265(For urgent referrals please phone the relevant number above)Page 1 of 1CR 11.1Palliative Care Quality End of Life Care Resource Book4

Palliative Care OutcomesCollaboration (PCOC) tools:Australia-modified Karnofsky Performance Scale (AKPS)Normal; no complaints; no evidence of diseaseAble to carry on normal activity; minor sign of symptoms of diseaseNormal activity with effort; some signs or symptoms of diseaseCares for self; unable to carry on normal activity or to do active workAble to care for most needs; but requires occasional assistanceConsiderable assistance and frequent medical care requiredIn bed more than 50% of the timeAlmost completely bedfastTotally bedfast and requiring extensive nursing care by professionals and/or familyComatose or barely rousableDeadScore1009080706050403020100POTENTIAL ACTIONS FOLLOWING RUG-ADL ASSESSMENT:ItemBed ecommended ActionsIndependent /supervision only1 Provide equipment if required (bed mobility aid orwalking aid etc.) Monitor for changesLimited physicalassistance3 Ensure plan clearly describes the assistance requiredby staff Consider a Fall Prevention Plan Provide equipment if requiredOther than two personphysical assist4 Provide equipment / device as required Ensure plan clearly describes the assistance requiredby staff and instructions regarding use of device Provide clear instructions to the patient regarding useof the deviceTwo or more personphysical assist5 Ensure plan clearly describes the assistance requiredby staff Provide equipmentIndependent /supervision only1Limited assistance2 Provide assistance required according to serviceguidelines / protocols Ensure plan clearly describes the assistance and aidsrequired by staffExtensive assistance /total dependence / tubefed3 Ensure plan clearly describes the assistance and aidsrequired by staff Provide mouth care according to service guidelines /protocols Allocate for patient who is totally dependent for allcare, including those in the terminal phaseTotal Score RangeRecommended Actions for Total ScoreTotal Score of 4-5Independent. MonitorTotal Score of 6-13Requires assistanceMay be at risk of falls and pressure areasTotal Score of 14-17Requires assistance of 1 plus equipmentGreater risk of falls and pressure areasTotal Score of 185 Monitor for changesRequires 2 assist for all careGreater risk of pressure areasPalliative Care Quality End of Life Care Resource Book

Palliative Care Outcomes Collaboration(PCOC) tool: PhasesThe palliative care phase identifies a clinically meaningful period in a patient’s condition. The palliative carephase is determined by a holistic clinical assessment which considers the needs of the patients and theirfamily and carers.STARTENDStablePatient problems and symptoms are adequatelycontrolled by established plan of care and Further interventions to maintain symptom controland quality of life have been plannedandThe needs of the patient and / or family/carerincrease, requiring changes to the existing planof care. Family/carer situation is relatively stable and nonew issues are apparent.UnstableAn urgent change in the plan of care or emergencytreatment is required because Patient experiences a new problem that was notanticipated in the existing plan of care,and/or Patient experiences a rapid increase in the severityof a current problem; and/or Family/ carers circumstances change suddenlyimpacting on patient care. The new plan of care is in place, it has beenreviewed and no further changes to the care planare required.This does not necessarily mean thatthe symptom/crisis has fully resolved but there isa clear diagnosis and plan of care (i.e. patient isstable or deteriorating) and/or Death is likely within days (i.e. patient is nowterminal).DeterioratingThe care plan is addressing anticipated needs butrequires periodic review because Patient condition plateaus (i.e. patient is now stable)or Patients overall functional status is decliningand An urgent change in the care plan or emergencytreatment and/or Patient experiences a gradual worsening of existingproblem and/or Family/ carers experience a sudden change in theirsituation that impacts on patient care, and urgentintervention is required (i.e. patient is now unstableor Patient experiences a new but anticipated problemand/or Family/carers experience gradual worseningdistress that impacts on the patient care. Death is likelyTerminal Patient dies orDeath is likely within days. Patient condition changes and death is no longerlikely within days (i.e. patient is now stable ordeteriorating).Bereavement – post death supportThe patient has died Case closure Bereavement support provided to family/carersis documented in the deceased patient’s clinicalrecord.Note: If counselling is provided to a family member orcarer, they become a client in their own right.M. Masso, S. Frederic. Allingham, M. Banfield, C. Elizabeth. Johnson, T. Pidgeon, P. Yates & K. Eagar, “Palliative carephase: inter-rater reliability and acceptability in a national study”, Palliative Medicine 29 1 (2014) 22–30.Palliative Care Quality End of Life Care Resource Book6

Abbey Pain ScaleAppendix 5: Abbey Pain ScaleFor measurement of pain in people with dementia who cannot verbaliseHow to use scale: While observing the resident, score questions 1 to 6Name of resident:Name and designation of person completing the scale:Date:Time:Latest pain releif given was:athoursQ1. Vocalisationeg. whipering, groaning, cryingAbsent - 0Mild - 1Moderate - 2Severe - 3Q1Q2. Facial Expressioneg. looking tense, frowning, grimacing, looking frightenedAbsent - 0Mild - 1Moderate - 2Severe - 3Q2Q3. Change in Body Languageeg. fidgeting, rocking, guarding part of body, withdrawnAbsent - 0Mild - 1Moderate - 2Severe - 3Q3Q4. Behavioural Changeeg. increased confusion, refusing to eat, alteration in usual patternsAbsent - 0Mild - 1Moderate - 2Severe - 3Q4Q5. Physiological Changeeg. temperature, pulse or blood pressure outside normal limits,perspiring, flushing or pallorAbsent - 0Mild - 1Moderate - 2Severe - 3Q5Q6. Physical Changeseg. skin tears, pressure areas, arthritis, contractures, previous injuriesAbsent - 0Mild - 1Moderate - 2Add scores for 1 - 6 and record here: Now tick the box that matches the Total 3-7 - MildQ6Total pain score 0-2 - No PainSevere - 38-13 - Moderate14 - SevereFinally tick the box which matches the type of painChronicAcuteAcute on ChronicAbbey, J; De Bellis, A; Piller, N; Esterman, A; Giles, L: Parker, D and Lowcay, B. Funded by the JH & JD Gunn Medical Research Foundation 1998 - 2002(This document may be reproduced with this acknowledgement retained)Australian Pain Society, Pain in Residential Aged Care Facilities: Management Strategies, 2nd Edition 1577Palliative Care Quality End of Life Care Resource Book

Abbey Pain ScaleModified Abbey Pain Scale (Follow on assessment TIMEDATEANDTIMEVOCALISATIONeg. whipering, groaning, cryingAbsent - 0Moderate - 2Mild - 1Severe - 3FACIAL EXPRESSIONeg. looking tense, frowning, grimacing,looking frightenedAbsent - 0Moderate - 2Mild - 1Severe - 3CHANGE IN BODYeg: fidgeting, rocking, guarding part ofbody, withdrawnAbsent - 0Moderate - 2Mild - 1Severe - 3BEHAVIOURAL CHANGEeg: increased confusion, refusing to eat,alteration in usual patternsgAbsent - 0Moderate - 2Mild - 1Severe - 3PHYSIOLOGICAL CHANGESeg: temperature, pulse or bloodpressure outside normal limits,perspiring, flushing or pallorAbsent - 0Moderate - 2Mild - 1Severe - 3PHYSICAL CHANGESeg: skin tears, pressure areas, arthritis,contractures, previous injuriesAbsent - 0Moderate - 2Mild - 1Severe - 3Total score Signature of personThe Abbey Pain Scale is an instrument designed to assist in the assessment of pain in patients who are unable toclearly articulate their needs, for example, patients with dementia, cognition or communication issues. The scale doesnot differentiate between distress and pain, so measuring the effectiveness of pain-relieving interventions is essential.The Australian Pain Society recommends the pain scale should be used as a movement-based assessment.Therefore observe the patient while they are being moved, during pressure area care, while showering, etc.Complete the scale immediately following the procedure and record the results on the Abbey Pain tool chart.A second evaluation should be conducted 1 hour after any intervention taken. If, at this assessment, the score onthe pain scale is the same, or worse, consider further intervention and act as appropriate. Complete the scale hourlyuntil the patient scores mild pain then 4 hourly for 24 hours treating pain if it recurs.If the pain/distress persists, undertake a comprehensive assessment of all facets of the patients care and monitorclosely over 24 hours including further intervention undertaken.If there is no improvement in that time, then it is essential to notify the GP of ongoing pain scores and actions taken.Modified from Hywel Dda University Health Board NHS 2013; Wales, UK158 Australian Pain Society, Pain in Residential Aged Care Facilities: Management Strategies, 2nd EditionPalliative Care Quality End of Life Care Resource Book8

Pain Management Using PainRecognition TechnologyPainChek is the world’s first pain assessment tool that has regulatory clearance inAustralia and Europe.Using AI and facial recognition technology, PainChek provides carers across multipleclinical areas with three important new clinical benefits: https://www.painchek.com/1. The ability to identify the presence of pain, when pain isn’t obvious2. To quantify the severity level of pain, when pain is obvious, and;3. To monitor the impact of treatment to optimise overall careFunding is available from the Department of HealthFollow this link to access the expression of interest (EOI) campaign for residential agedcare organisations to complete 12 month funded grants available:http://painchek.com/painchek-grant/How to organise an ImplantableCardioverter Defibrillator (ICD) to beturned off1. Ensure family are aware, understand and give consent.2. D iscuss with the GP and ensure that the GP has documented and authorised thedefibrillator to be turned off in the patient’s progress notes3. C ontact the person’s cardiologist (you may need to ask family if you cannot finddetails in file)4. Ask cardiologist which implantable defibrillator was used.5. C ontact the company and ask for the local area representative contact details.Contact the rep and request a visit to deactivate the deviseFor more information: https://www.aci.health.nsw.gov.au/ s.pdf9Palliative Care Quality End of Life Care Resource Book

ISBAR Tool to Assist withEffective CommunicationISBAR Clinical HandoverISBAR Clinical DeteriorationIntroductionIntroduction Introduce yourself, your role and location Introduce yourself, your role and location Identify team leader Identify the patient Clearly identify patient and family andcarer if presentSituationSituation State the immediate clinical situation State particular issues, concerns or risks Identify risks – deteriorating patient, fallsrisk, allergies, limitations to resuscitation State the immediate clinical situationBackground Provide relevant clinical history andbackground Presenting problems and clinical historyAssessmentBackground Provide relevant clinical history referringto medical record and/or eMR Work through A-G physical assessmentAssessment What do you think the problem is? Work through A-G physical assessment Refer to observations, medication andother patient charts Summarise current risk managementstrategies Have observations breached CERScriteria? What clinical observations are ofparticular concern? Remember to have current observationsand information ready!Recommendation What do you want the person you havecalled to do? What have you done?Recommendation Be clear about what you are requestingand the timeframe Recommendations for the shift Repeat to confirm what you have heard Refer to medical record or eMR What further assessments and actionsare required by who and when State expected frequency ofobservationsPlease refer to the Aged Care RapidResponse Team Flip Chart for moreinformation Request that receiver read backimportant actions requiredPalliative Care Quality End of Life Care Resource Book10

Palliative Care Equipment Stock ListPRN or 4/24 subcutaneous medication administration1Puncture proof receptable - kidney dish2Gloves3BD saf-t-intima24g 0.75inRef: 3833134Smart site needle free valveCare fusion 11717232Ref: 2000E5 Normal saline or water forinjection for flushing610ml ampoulesAlcohol wipes7 Permeable transparentdressing - IV3000, Tegaderm6cm x 6cmRef: 9354HP8Drawing up needles18g 1/2 12mm x 38mmRef: 3002049BD 1ml syringeRef: 30962810BD 3ml syringeRef: 30211311BD 5ml syringeRef: 302135For Syringe Drivers1BD Plastipak 20mls (leur lock)2 E xtension setMicrobore 150mmPriming volume 1.2mlsRef: 300629Ref: 503.073Alkaline 9V battery4For Subcutaneous Use Only’ LabelPressure Area Protection and use in Pressure Injury1 Mepilex with safetactechnology10cm x 10cmMolnycke Health CareRef: 73107911033102Mepilex border7.5cm x 7.5cmRef: 16373613Mepilex border10cm x 10cmRef: 163737011Palliative Care Quality End of Life Care Resource Book

Palliative Care Essential Equipment1. Bicarbonate impregnated mouth swabs2. Lip balm3. Oral balance gel4. Aqua mouth spray5. Sorbolene body lotion/cream6. Sudocream7. Dermalux soft towel lotion8. Dry shampoo9. Essential / aromatherapy oils10. Ozone electric air diffuser11. Oxygen ear protector12. Nozoil nasal drops13. Fess nasal spray14. Zeoz105 Bag of Rocks (odour control rocks)15. Lubricating eye drops such as polytears16. Extra pillows17. CD player and the person’s favourite music18. Desk or room fan19. Pressure relieving mattressPalliative Care Quality End of Life Care Resource Book12

Palliative Care End of Life Medications– Initial Suggested DosesPAIN / SHORTNESS OF BREATHa) If not on an opioid: If no SOB or pain: Morphine 2.5-5mg S/C q2/24 prn(Max 6 doses per 24hrs)If pain or SOB present: Morphine 2.5mg s/c q4-6/24 regularly plusMorphine 2.5-5mg S/C q 2/24 prn(Max 6 additional PRN doses per 24hrs).b) If pain or SOB present: Convert regular oral opioid to s/c morphine q4/24plus 1/6th total daily dose s/c q 2/24 prn(Max 6 doses per 24hrs)Please refer to the Drug Conversion Guide, Page 14.For impaired renal function or if there is a morphine allergy: suggest charting S/CHydromorphone 0.5mg instead of S/C Morphine 2.5mg PRN max 6 doses per 24hrs.Please refer to the Opioid Conversion Guide on page 14.NAUSEA & VOMITINGMetoclopramide 10 mg s/c QID regularly(if nausea present) or prn (if no nausea)O

1 Palliative Care Quality End of Life Care Resource Book Palliative Care Needs Round Checklist (Based on the ACU and Calvary Palliative Care Needs Rounds Checklist) Palliative Care Needs Round Checklist Triggers to discuss resident at needs rounds One or more of: 1. You would not be surprised if the resident died in the next six months 2.