Verification of Expected Death by Nursing Staff

Transcription

1 Verification of Expected Death by Nursing Staff Approved 13 / 05 / 2011 Version 1.0 Date of First Issue 01 / 04 / 2006 Review Date 31 / 07 / 2014 Date of Issue 02 / 07 /2009 EQIA Yes Author / Contact Palliative Care MCN Group / Committee Final Approval Forth Valley Managed Clinical Network Palliative Care Management Committee - This document can, on request, be made available in alternative formats Version 1 13 th May 2011 Page 1 of 28

2 NHS Forth Valley Consultation and Change Record Contributing Authors: Paul Baughan, Forth Valley Lead Cancer GP Jacqueline Bryceland, Practice Development Unit, Forth Valley Acute Services Fiona Downs, Consultant in Palliative care, Strathcarron Hospice Erna Haraldsdottir, Education Department, Strathcarron Hospice Fiona Hutton, FV Palliative Care Nurse Facilitator for Community Hospitals Stuart Hislop, Teaching Fellow, University of Stirling Avril Magill, Clinical Nurse Manager, Forth Valley Primary Care Services Arlian Mallis, Practice Development Unit, Forth Valley Acute Services Liz Walker, Forth Valley Cancer and Palliative Care Facilitator Margaret Ramsay, Cancer & Palliative Care Facilitator Karen McArthur, Palliative Care Facilitator for Community Hospitals Consultation Process: Through FV Palliative Care MCN Distribution: Clinical staff within NHS Forth Valley and Strathcarron Hospice Change Record Reviewed 2009 to include new code of standards for midwifery and nursing and to include new DNA-CPR policy Version 1 13 th May 2011 Page 2 of 28

3 CONTENTS 1 Introduction 4 Page 2 Verification of expected death procedure for deaths at home 6 3 Verification of expected death procedure for deaths in Hospital 6 4 Verification of expected death procedure for deaths within the Hospice 7 5 Training for nurses on verification of death 7 6 Nurse verification of death 8 Appendix 1 Deaths to be reported to the procurator fiscal 9 Appendix 2a Flow Chart for verification of death at home 11 Appendix 2b Flow Chart for verification of death in hospital 12 Appendix 2c Flow Chart for verification of death in Community Hospitals 13 Appendix 2d Flow Chart for verification of death within Hospice 14 Appendix 3a Verification of Expected Death Form Home 15 Appendix 3b Verification of Expected Death Form Hospital 17 Appendix 3c Verification of Expected Death Form Hospice 19 Appendix 4 Training 21 Appendix 5 Example of the special patient note screen on Taycare 22 Appendix 6 Example of Taycare call sheet for communicating expected death back to GP practice 23 Appendix 7 Cultural and religious considerations 24 Appendix 8 Example of Do Not Attempt Cardiopulmonary 26 Resuscitation (DNACPR)* References and other sources of information 27 Version 1 13 th May 2011 Page 3 of 28

4 Verification of Expected Death by Nursing Staff 1 Introduction 1.1 It is essential that all professionals involved in caring for a patient after death, do so in a compassionate and caring manner, as this is often the last service that can be provided for an individual, and it may ease the distress of those who are bereaved. 1.2 The purpose of this document is to provide guidance regarding the process for verification and certification of expected death within Forth Valley. This guidance is applicable to all care settings (hospice, hospital and community). This will be of particular importance out of normal working hours, when the doctor on duty may not know the patient. Accountability & Responsibility The Code: Standards of conduct, performance and ethics for nurses and midwives As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions. You must: always act lawfully, whether those laws relate to your professional practice or personal life. have the knowledge and skills for safe and effective practice when working without direct supervision recognise and work within the limits of your competence keep your knowledge and skills up to date throughout your working life keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been complete records as soon as possible after an event has occurred ensure any entries you make in someone's paper records are clearly and legibly signed, dated and timed This Code was approved by the NMC s Council on 6 December 2007 for implementation on 1 May 2008 All registered nurses performing this role must have undertaken approved training. Version 1 13 th May 2011 Page 4 of 28

5 Sudden or Unexpected Deaths Sudden or unexpected deaths are excluded from this guidance. If a medical practitioner is contacted in or out-of-hours regarding the sudden death of a patient, he should attend to confirm death and report the death to the Procurator Fiscal either directly or via the police. Detailed guidance is given in appendix 1, regarding which deaths should be reported to the Procurator Fiscal. In particular, deaths from accidents, deaths where a complaint is pending and deaths from industrial diseases e.g. mesothelioma must be reported. If there is any uncertainty as to whether a death is sudden or unexpected, then the medical practitioner must be contacted 1.3 Expected death is defined as: A death where the patient s demise is anticipated in the near future therefore death was expected and plans have been put in place and the cause of death is known. There are no suspicious circumstances to suggest that anything untoward has occurred For the purposes of this procedure, it is also a death where a doctor will be able to issue a medical certificate as to the cause of death. 1.4 This procedure is applicable to all care settings within Forth Valley. Deaths within care homes will follow the procedure outlined for death at home and deaths within Community Hospitals will follow the procedure outlined for death in hospital Version 1 13 th May 2011 Page 5 of 28

6 2 Verification of expected death procedure for deaths at home 2.1 Prior to death 2.11 Wherever possible, the fact that death is expected should be shared with the patient next of kin and other responsible parties The patient s GP should indicate in the medical records that death is expected and that further intervention to prolong life would be inappropriate The first part of the attached verification of death form (appendix 3a) should be completed and should remain with the patient (consider leaving with the Gold Standards Framework Home pack if applicable) Information should be communicated to NHS 24 via the Taycare special patient notes to indicate that death is expected and that the patient is not for resuscitation. Please complete Forth Valley DNAR Form (Appendix 8) 2.2 Procedure for responding to an expected death 2.21 For a death within normal working hours, and particularly when relatives are at the scene, a GP should normally attend as soon as practicable given the urgent needs of their living patients If the death occurs out-of-hours and / or the usual GP is unavailable, then the fact of death should be verified by a suitably qualified and trained registered nurse, if such a nurse is available. Documentation should be completed as per the protocol below Where a qualified nurse is not available to verify death then an on-call doctor should attend as soon as practicable given the urgent needs of their living patients If verification of death is undertaken out-of-hours by a nurse in the community, then the normal out-of-hours contact sheet should be completed (appendix 6) 3.0 Verification of expected death procedure for deaths in Hospital 3.1 Prior to death 3.11 Wherever possible, the fact that death is expected, should be shared with the patient, nearest of kin and other responsible parties The patient s doctor should indicate in the medical records that death is expected and that further intervention to prolong life would be inappropriate The first part of the attached verification of death form (appendix 3b) should be completed and should be filed within the patient s medical records. 3.2 Procedure for responding to an expected death For a death within normal working hours, and particularly when relatives are at the scene, the responsible doctor should normally attend as soon as practicable given the urgent needs of their living patients If the death occurs out-of-hours and / or the usual doctor is unavailable, then the fact of death should be verified by a suitably qualified and trained nurse, if such a nurse is available. Documentation should be completed as per the protocol below. Version 1 13 th May 2011 Page 6 of 28

7 3.2.3 Where a qualified nurse is not available to verify death then an on-call doctor should attend as soon as practicable given the urgent needs of their living patients If verification of death is undertaken by a nurse, then the medical / surgical team responsible for the patient should be contacted at the start of the next working day. The GP must also be contacted. 4 Verification of expected death procedure for deaths within the Hospice 4.1 Prior to death Wherever possible, the fact that death is expected, should be shared with the patient, nearest of kin and other responsible parties The Hospice doctor should indicate in the medical records that death is expected and that further intervention to prolong life would be inappropriate The first part of the attached verification of death form (appendix 3c) should be completed and should be filed in the patient s notes. 4.2 Procedure for responding to an expected death For a death within normal working hours, and particularly when relatives are at the scene, the on-call hospice doctor should attend as soon as practicable given the urgent needs of their living patients If the death occurs out-of-hours and there is no doctor on the premises, then the fact of death should be verified by a suitably qualified and trained nurse, if such a nurse is available. Documentation should be completed as per the protocol below The Hospice doctor on-call be notified at the start of the next day, so that death certification can take place. At all times consideration should be given to any cultural or religious preferences relating to death (appendix 7) 5 Training for nurses on verification of death 5.1 Training in death verification will be provided for registered nurses, where there is an identified clinical need and in line with current guidance. 5.2 All registered nurses who are likely to engage with the protocol for verification of death by nurses must attend the recommended training for this event. 5.3 Following introductory training all registered nurses must judge their competence within this procedure and engage in updates of training if and when appropriate. 5.4 Approved courses in verification of expected death will be available from Strathcarron Hospice and NHS Forth Valley. Updates are available from palliative care nurse facilitators working in NHS Forth Valley. Version 1 13 th May 2011 Page 7 of 28

8 6.0 Nurse Verification of death 6.1 The identity of the patient should be confirmed 6.2 The Verification of Death Form must be readily available and the first part must have been completed 6.3 The nurse will ascertain that death has occurred by checking the following physiological signs: Absence of carotid pulse for over one minute Absence of heart sounds for over one minute Absence of respiratory movement and breath sounds over one minute Fixed and dilated pupils which are un-reactive to light 6.4 The nurse must be clear that there are no circumstances outlined in appendix 1 which would necessitate involvement of the Procurator Fiscal. If there is any doubt, the duty doctor should be contacted. 6.5 The nurse should spend appropriate time with the family or next of kin to help them with any immediate distress. The booklet What to do after a death in Scotland should be made available to the relatives wherever possible. It may also be appropriate to provide a copy of the Forth Valley Bereavement Booklet. 6.6 Where an expected death as defined above has occurred, and has been verified, the body may be removed to the Hospital mortuary. In the Community, the body may be removed by a funeral director to a location likely to be convenient to the usual GP. This should ideally be agreed in advance of the event. 6.7 The second part of the verification of death form (appendix 3), must be completed and communicated to the GP practice at the start of the next working day. The usual medical practitioner should then make arrangements to issue the death certificate with the minimum of delay. Version 1 13 th May 2011 Page 8 of 28

9 Appendix 1 Procurator Fiscal notification The Procurator Fiscal s best known role is as the local public prosecutor but he or she has a separate duty to investigate all sudden, suspicious, accidental, unexpected and unexplained deaths and any deaths occurring in circumstances causing serious public concern. The following categories of deaths must be reported to the Procurator Fiscal. 1. Sudden deaths e.g. relating to an accident, suicide or homicide 2. Deaths related to neglect or complaint e.g. where a complaint is received by a Health Board or NHS Trust regarding the medical treatment given to a patient with a suggestion that the treatment may have contributed to the death of the patient. 3. Deaths of children 4. Public Health concerns o Any death caused by an industrial disease or industrial poisoning o Any death due to a disease, infectious disease or syndrome which poses an acute, serious public health risk 5. Deaths associated with medical or dental care 6. Any death not falling into any of the foregoing categories where the cause remains uncertified or where the circumstances of the death may cause public anxiety. In palliative situations the main reason to refer to the PF are deaths from Industrial Diseases (Mesothelioma), accidents and deaths where a complaint of medical negligence has been lodged prior to death. If there is any uncertainty about whether a death should be reported initial contact is made by telephone using a Reporting checklist (See below) For death associated with medical care complete form F89 (available from and or fax to the PF The PF will then direct police officers to visit and interview relatives and staff. A Post Mortem may or may not be required. Locally the use of the Mesothelioma pro forma (See FV PC Manual) may reduce distress to relatives as its completion and transmission to the PF will obviate the need for police to interview family members. References Death and the Procurator Fiscal Crown Office Publication November 2008 Link to publication Version 1 13 th May 2011 Page 9 of 28

10 Reporting checklist 1. Check whether you are required to report the death to the Procurator Fiscal and be sure you understand why the death is being reported. If you are in any doubt about the need to report, consult the Procurator Fiscal before issuing a Death Certificate. 2. Check where the accident or other event which caused the death occurred. 3. Refer to Annex 1 of this document to identify the appropriate Procurator FIscal to receive the report (if in doubt consult your local Procurator Fiscal). 4. Before telephoning the Procurator Fiscal check that you have the following information to hand: Name of deceased Age and/or date of birth Home address Religion/ethnic origin Place, date and time of death Nearest relatives (if known) and whether they have any special needs e.g. translation General Practitioner (if known) History Cause of death if ascertained and whether the death can be certified The name of the doctor who proposes to sign any death certificate Whether the family have any concerns about the circumstances of the death 5. If the death is associated with medical care, complete Form F89 (see ) and forward it by fax or to the Procurator Fiscal. Version 1 13 th May 2011 Page 10 of 28

11 APPENDIX 2a Version 1 13 th May 2011 Page 11 of 28

12 APPENDIX 2b Version 1 13 th May 2011 Page 12 of 28

13 APPENDIX 2c Version 1 13 th May 2011 Page 13 of 28

14 APPENDIX 2d Version 1 13 th May 2011 Page 14 of 28

15 Appendix 3a: VERIFICATION OF EXPECTED DEATH FORM Part 1: VERIFICATION OF EXPECTED DEATH (For completion by doctor) HOME CHI No: Surname: Forename: Address: Date of Birth: Sex I, Dr., being the Medical Officer in charge of this patient, am aware that his/her death is imminent and expected, as are his/her relatives. I therefore give my permission for the designated nurse on duty who is competent to verify death, to do so in my absence. Contact Details: Any special cultural or religious requirements: Signature: Date: (Certificate is valid for 28 days) Print Name: Reviewed on (Date): By (Print Name): Signature: This certificate should be filed within the patient s hospital / care home medical records. For patients living at home, this certificate should be left in a convenient place within the home for access by health professionals (e.g. Home pack for Gold Standards Framework practices), and NHS 24 should be informed about its existence. Version 1 13 th May 2011 Page 15 of 28

16 Part 2: VERIFICATION OF PATIENT S DEATH - HOME (For completion by nurse) CHI No: Surname: Forename: Circulation Respiration Cerebral Function Absent Carotid Pulse Absent Respiratory Effort Absent Eye Movements Absent Heart Sounds on Auscultation for over 1 minute Absent Breath Sounds on Auscultation for over 1minute Pupils fixed and Dilated (use pen torch) Pupils Unreactive to Light (use pen torch) I have undertaken appropriate training and achieved competency in verification of expected death. I have verified the death of Verification of death by Nursing Staff on:, following the Forth Valley Protocol for Date: at Time: Dr was informed on Time: at Attachments removed: (circle as appropriate) Catheter: Syringe Pump: PEG Tube Tracheostomy Tube Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Persons present at time of death Details of any advice regarding controlled drugs left in house: Advice / Information given to relatives - e.g. What to do after death and Bereavement Booklet Arrangements for collection / delivery of death certificate Potential bereavement issues identified Signature(s) of Verifying Nurse(s): Print Name(s): Date: (Community nursing staff must inform the Out of Hours medical and nursing service that verification of death has taken place. Please leave this form in the patient s house with any other medical / nursing documentation). Version 1 13 th May 2011 Page 16 of 28

17 Appendix 3b: HOSPITAL VERIFICATION OF EXPECTED DEATH FORM Part 1: VERIFICATION OF EXPECTED DEATH (For completion by doctor) CHI No: Surname: Forename: Date of Birth: Address: Sex: I, Dr., being the Medical Officer in charge of this patient, am aware that his/her death is imminent and expected, as are his/her relatives. I therefore give my permission for the designated nurse on duty who is competent to verify death, to do so in my absence. Contact Details: Any special cultural or religious requirements: Signature: Date: (Certificate is valid for 14 days) Print Name: Reviewed on (Date): By (Print Name): Signature: Version 1 13 th May 2011 Page 17 of 28

18 Part 2: VERIFICATION OF PATIENT S DEATH - HOSPITAL (For completion by nurse) CHI No: Surname: Forename: Circulation Respiration Cerebral Function Absent Carotid Pulse Absent Respiratory Effort Absent Eye Movements Absent Heart Sounds on Auscultation for over 1 minute Absent Breath Sounds on Auscultation for over 1minute Pupils fixed and Dilated (use pen torch) Pupils Unreactive to Light (use pen torch) I have undertaken appropriate training and achieved competency in verification of expected death. I have verified the death of Verification of death by Nursing Staff on:, following the Forth Valley Protocol for Date: at Time: Dr was informed on Time: at Attachments removed: (circle as appropriate) Catheter: Syringe Pump: PEG Tube Tracheostomy Tube Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Others (please specify)... Persons present at time of death Advice / Information given to relatives - e.g. What to do after death and Bereavement Booklet Arrangements for collection / delivery of death certificate Potential bereavement issues identified Signature(s) of Verifying Nurse(s): Print Name(s): Date: (Please file this form in the front of the patient s medical records behind the Advanced Medical Directive divider and ensure that the registered GP is informed as per ward policy) Version 1 13 th May 2011 Page 18 of 28

19 Appendix 3C HOSPICE VERIFICATION OF EXPECTED DEATH FORM Part 1: VERIFICATION OF EXPECTED DEATH (For completion by doctor) CHI No: Surname: Forename: Date of Birth: Address: Sex: I, Dr., being the Medical Officer in charge of this patient, am aware that his/her death is imminent and expected, as are his/her relatives. I therefore give my permission for the designated nurse on duty who is competent to verify death, to do so in my absence. Contact Details: Any special cultural or religious requirements: Signature: Date: (Certificate is valid for 7 days) Print Name: I, Dr., being the Medical Officer in charge of this patient, am aware that his/her death is imminent and expected, as are his/her relatives. I therefore give my permission for the designated nurse on duty who is competent to verify death, to do so in my absence. Contact Details: Any special cultural or religious requirements: Signature: Date: (Certificate is valid for 7 days) Print Name: Version 1 13 th May 2011 Page 19 of 28

20 Part 2: VERIFICATION OF PATIENT S DEATH - HOSPICE (For completion by nurse) CHI No: Surname: Forename: Circulation Respiration Cerebral Function Absent Carotid Pulse Absent Respiratory Effort Absent Eye Movements Absent Heart Sounds on Auscultation for over 1 minute Absent Breath Sounds on Auscultation for over 1minute Pupils fixed and Dilated (use pen torch) Pupils Unreactive to Light (use pen torch) I have undertaken appropriate training and achieved competency in verification of expected death. I have verified the death of Verification of death by Nursing Staff on:, following the Forth Valley Protocol for Date: at Time: Dr was informed on Time: at Attachments removed: (circle as appropriate) Catheter: Syringe Pump: PEG Tube Tracheostomy Tube Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Y / N / Not Applicable Others (please specify)... Persons present at time of death Details of any advice regarding controlled drugs left in house: Advice / Information given to relatives - e.g. What to do after death and Bereavement Booklet Arrangements for collection / delivery of death certificate Potential bereavement issues identified Signature(s) of Verifying Nurse(s): Print Name(s): Date: Version 1 13 th May 2011 Page 20 of 28

21 Appendix 4: Training All nurses undertaking verification of expected death are required to complete an approved training programme, with regular updates. Within Forth Valley, an agreed training programme has been developed and is being delivered by each of the following units. Strathcarron Hospice Education Department: Catherine Haggerty, NHS Forth Valley Practice Development Unit: NHS Forth Valley Lead Cancer Team: Updates in Verification of expected death can be obtained by contacting: Forth Valley Lead Cancer Team telephone: Sandra Campbell, Nurse Consultant in Cancer and Palliative Care telephone: Version 1 13 th May 2011 Page 21 of 28

22 Appendix 5: Example of the special patient note screen on Taycare Prostate cancer 2008 with widespread boney metastasis. Semi-conscious and taking no fluids by mouth. Syringe pump for pain relief. Comfortable. Prostate Wife and cancer daughter 2008 caring with for widespread patient with boney support metastasis. from professional Semi-conscious carers and twice taking daily, no DNs fluids and by Hospice mouth. homecare Syringe pump team. for Death pain relief. imminent Comfortable family. Wife aware. and Would daughter prefer caring to remain for patient at home. with support LCP commenced from professional 21/08/09. carers twice DNAR daily, (allow DNs natural and Hospice death) form homecare completed team. Death imminent family aware. Verification Would of expected prefer to remain death form at home. completed LCP and commenced in GSFS 21/08/09. Homecare DNAR pack at (allow home natural death) form completed Verification of expected death form completed and in GSFS Homecare pack at home Version 1 13 th May 2011 Page 22 of 28

23 Appendix 6: Example of Taycare call sheet for communicating expected death back to GP practice. Verification of expected death form completed. Relatives will contact GP practice tomorrow morning for death certificate. Burial Version 1 13 th May 2011 Page 23 of 28

24 Appendix 7: Cultural and religious considerations Summary of cultural and religious considerations will be highlighted here Table 1 Summary of requirements after death for commonest religions, beliefs or cultures Religion, Belief or Culture African- Caribbean Cremation Burial Scientific Research/PM Transplants Special Instructions Some are cremated Some are returned to their homeland for burial Most are buried in Britain Baha is No Yes Not more than 1 hour s journey from place of death No embalming Buddhists Yes Some may choose burial Post mortems are offensive unless legal requirement General reluctance but attitudes changing The funeral is elaborate and may be delayed to allow family to gather. The body may be viewed several times prior to the funeral Yes Yes The family or Local Assembly will arrange the funeral. Yes Yes but decision made on what causes least harm and promotes greatest good Contact Buddhist priest. Wrap in sheet without emblems. Leave 12 hours. Committal should be within 3-7 days depending on the lunar calendar Christians Yes Yes Yes Yes Contact priest or minister and undertaker Hindus Yes Children under 5 years No Leave body covered. Relatives wa body and put on new clothes PM only if unavoidable. All organs should be returned to body before cremation to ensure peace in the afterlife Humanists Yes Yes No objections No objections Do not dress body in religious vestment. There should be no religious symbolism on view Jehovah s Witnesses Fiona Downs 2006 Yes Yes Personal choice Personal choice Medical directive card carried which has 2 contact names if patient unable to express wishes sh Version 1 13 th May 2011 Page 24 of 28

25 Religion, Belief or Culture Cremation Burial Scientific Research/PM Transplants Special Instructions Jews Mormons (Church of Jesus Christ of Latter-day Saints) Yes if Yes if Orthodox Only if legal Orthodox Jews Do not leave body alone. If rabbi Progressive Within 24 hours requirement for No except unavailable, hospital staff may close or Nonobservant PM corneas Liberal or eyes and tie up jaw. Keep arms and hands straight and by sides. Remove Reformed Jews - Yes tubes and plug incisions. Wrap body in a clean sheet without emblems and place in mortuary Not Preferred No religious Personal or family No special requirements but the encouraged objections choice sacred garment, if worn, must be Personal choice replaced on the body. The President of the church s women s organization will help the family in dressing the body of a deceased female for burial. Moslems No Yes as s oon as possible Sikhs Fiona Downs 2006 Yes with 5 K signs Kesh uncut hair Kangha the comb Kara steel bangle Kirpan short sword/dagger Kachha white shorts Yes for stillborn children only No No PM if possible. Organs to be buried with body Only if legally unavoidable No Yes If non-moslem, staff wear gloves and turn head towards right shoulder. Wrap in plain sheet. Next of kin washes body before burial. Body is washed and white clothes put on before cremation Version 1 13 th May 2011 Page 25 of 28

26 Appendix 8 Version 1 13 th May 2011 Page 26 of 28

27 References and other sources of information: NMC 2004, The Code of Professional Conduct, Nursing and Midwifery Council Death and the Procurator Fiscal: Crown Office 1998 Devon Local Medical Committee procedure for verification of death North Staffordshire Verification of death Exeter PCT, 2003, Verification of expected death by a registered nurse employed by Exeter PCT, Nursing Protocol. Exeter Primary Care Trust What to do after a death in Scotland Religions and cultures a guide to beliefs and customs for health care staff and social services Dr Moussa Jogee and Mrs Saroj Lal This procedure was produced by collaborative working between the following people: Paul Baughan, Forth Valley Lead Cancer GP Jacqueline Bryceland, Practice Development Unit, Forth Valley Acute Services Fiona Downs, Consultant in Palliative care, Strathcarron Hospice Erna Haraldsdottir, Education Department, Strathcarron Hospice Fiona Hutton, FV Palliative Care Nurse Facilitator for Community Hospitals Stuart Hislop, Teaching Fellow, University of Stirling Avril Magill, Clinical Nurse Manager, Forth Valley Primary Care Services Arlian Mallis, Practice Development Unit, Forth Valley Acute Services Liz Walker, Forth Valley Cancer and Palliative Care Facilitator Approved by: Forth Valley Managed Clinical Network Palliative Care 6 th March 2006 Forth Valley Out of Hours Clinical Governance Committee 16 th Feb 2006 Forth Valley Safe and Effective Care Group April 2006 Strathcarron Hospice Management Team March 2006 Forth Valley GP Subcommittee 16 th May 2006 Reviewed on 2 nd July 2009 by: Margaret Ramsay, Cancer & Palliative Care Facilitator Karen McArthur, Palliative Care Facilitator for Community Hospitals Erna Haraldsdottir, Education, Strathcarron Hospice Paul Baughan, Lead Cancer GP Version 1 13 th May 2011 Page 27 of 28