Client Summary Palliative Care

Transcription

1 Client Summary Palliative Care DRAFT 2, March 2014 Gippsland Region Palliative Care Consortium Clinical Practice Group Policy No. Title Keywords Ratified GRPCC Client Summary Palliative Care After-hours, palliative care, triage and symptom management GRPCC Clinical Practice Group Effective Date Review Date Purpose Every two years from effective date. To specify a minimum client data set required for: best practice care planning; and effective communication of palliative care client information between service providers. Pages 6

2 Background The Victorian Department of Health has provided funding to improve after-hours support for palliative care clients. An After-hours palliative care framework 1 (the Framework) was released in 2012 to assist palliative care consortia to develop models of after-hours support for their regions. Six key elements of an after-hours palliative care model are identified; 1. Best practice care planning 2. Client information systems 3. After-hours telephone triage 4. After-hours nursing support 5. After-hours medical support 6. Activity following an after-hours contact and quality assurance While developing a Gippsland After-Hours Palliative Care Model, the GRPCC identified a need for a Client Summary Palliative Care. The purpose of this document is to specify a minimum client data set required for: best practice care planning; and effective communication of palliative care client information between service providers. Therefore, the Client Summary Palliative Care addresses the following key elements of the Framework: 1. Best practice care planning is facilitated by completing all items in the Client Summary Palliative Care. 2. Client information systems should incorporate the Client Summary Palliative Care items. 3. After-Hours telephone triage will be better informed by the Client Summary Palliative Care, providing the triage nurse with relevant information required to successfully triage any after-hours phone calls. The Client Summary Palliative Care will also assist communication more broadly than after-hours service provision for palliative care clients. Any communication with other service providers will be more informed if all items in the Client Summary Palliative Care is completed, e.g. secondary consultations, referrals etc. 1 Victorian Government Department of Health, After-hours palliative care framework, 2012.

3 Patient name Home address Phone home Date of Birth Gender Phone mobile Patient living alone GP Available - home visits name and phone Contactable by phone after-hours Main carer Address (if different to patient address) Admission to service date Main diagnosis Relationship Phone Reason for admission Medical history Client alerts Cautions / allergies/ risk management Phase of illness Karnofsky scale Current treatments chemotherapy, radiotherapy, other, Not applicable Current symptoms; Physical, Psychosocial and Other Problem severity score 0-3 Current Medication Doses

4 Phase Definitions The Palliative care phase is the stage of the patient s illness. Palliative care phases are not sequential and a patient may move back and forth between phases. Palliative care phases provide a clinical indication of the level of care required and have shown to correlate strongly with survival within longitudinal prospective studies. PALLIATIVE CARE PHASE OF ILLNESS Clinician rated 1. STABLE Symptoms are adequately controlled by established management 2. UNSTABLE Development of a new problem or a rapid increase in the severity of existing problems 3. DETERIORATING Gradual worsening of existing symptoms or the development of new but expected problems 4. TERMINAL Death likely in a matter of days 5. BEREAVED Death of a patient has occurred and the carers are grieving Refer to complete Phase Definitions KARNOFSKY SCALE AKPS (Australian modified Karnofsky Performance Scale) Clinician rated 100 Normal, no complaints or evidence of disease 90 Able to carry on normal activity, minor signs or activity 80 Normal activity with effort, some signs or symptoms of disease 70 Care for self, unable to carry on normal activity or to do active work PROBLEM SEVERITY SCORE Clinician rated 0 = Absent 1 = Mild 2 = Moderate 3 = Severe 60 Occasional assistance but is able to care for most needs 50 Requires considerable assistance and frequent medical care 40 In bed more than 50% of the time 30 Almost completely bedfast 20 Totally bedfast & requiring nursing care by professionals and/or family 10 Comatose, barely rousable

5 Current signed anticipatory medication and syringe driver orders Doses Are anticipatory medication and syringe driver orders available in the home? Is injectable medication available in the home? Are syringes/needles available in the home? Is there a sharp container in the home? Planning Does the client want to be cared for at home? Is the caregiver managing care at home? Does the client want to die at home? Does the caregiver want the client to die at home? Carer s Symptom Management Sheets provided? List symptoms for which provided Date Date commenced Date completed Carer s Kit provided Advance Care Planning (ACP) End of Life Care (EOLC) Planning Medical Enduring Power of Attorney (MEPOA) Funeral arrangements made Comments: Date: Name of nurse completing summary: Position and department:

6

7 Appendix 2 Sample form After-Hours Call Summary Date of call: Name of Triage Nurse: Position and department: Person making after-hours phone call: Client Caregiver Other... Reason(s) for call Symptom related New Exacerbation Pain Anxiety- client / caregiver Nausea and/or vomiting Breathlessness Terminal restlessness Constipation Death Other symptom Other reason(s) Problem severity score 0-3 Notes Response to call Yes No Notes Issue resolved through phone call only Home visit after-hours required Visit recommended following day Contacted palliative care nurse Ambulance called Admission to hospital Other response