Healthcare Professionals

• Urgent assessment and treatment of potentially reversible deterioration in line with wishes and advance care planning
• Frequent reassessment, review of goals of care and communication with patient and carer
• If in hospital, consider initiating AMBER Care Bundle

• Urgent assessment and treatment of potentially reversible deterioration in line with wishes and goals of care - Far West Palliative & End of Life Medical Goals of Care

• Western NSW PHS: Factsheet for GPs – Medicare Billing in RACFs

• Amber care bundle - please visit: 
  https://www.cec.health.nsw.gov.au/improve-quality/teamwork-culture-pcc/person-centred-care/end-of-life

• Reassess holistic care needs frequently
• Review goals of care and holistic care plan to address current and future anticipated need
• Discussion at MDT Case Conference

• Far West Palliative & End of Life Medical Goals of Care  
• Western NSW PHN: Factsheet for GPs – Medicare Billing in RACFs

• Communicate with patient and carer

• Communicate with patient and carer – PREPARED model
• Palliative approach leaflet

• Review and update Advance Care Plan / Advance Care Directive and goals of care
• Confirm Preferred Place of Care (PPC) and consider transfer to PPC, if appropriate
• Initiate or review resuscitation discussion
• Complete Resuscitation Plan, if not already done
• Complete Ambulance Plan, if not already done
• Complete Expected Death form, if at home

• Initiate advance care planning discussions
• Advance care planning documentation – Advance care plan and end of life wishes form
• Advance care directive – NSW Health Advance Care Directive 
• Surrogate decision maker – NSW Guardianship Division Person Responsible factsheet
• NSW Capacity Toolkit
• Advance Care Planning Australia: Factsheet for GPs - Advance care planning in general practice: Guidance on the use of Medicare Benefits Schedule Items
• Advance Care Planning Australia – Factsheet for Healthcare Professionals
• Advance Care Planning Australia – Factsheet for GPs
• NSW Trustee Guardian - Enduring Guardianship
• NSW Government: Enduring Guardianship - Planning for your future health and lifestyle decisions 

• Initiate resuscitation discussions – NSW Health PD2014_030
• Resuscitation Plan - Adult form (also on pages 22-23 of PD2014_030)
• Resuscitation Plan – Paediatric form (also on pages 24-25 of PD2014_030)

• NSW Ambulance Adult and Paediatric Palliative Care Plans

•  Verification of Death and Medical Certificate of Cause of Death

• Optimise symptom management
• Rationalise regular medications
• Prescribe anticipatory crisis drugs and orders
• Ensure drug administration equipment in situ

• FWLHD Palliative Care Symptom Management Pocket Guide
• FWLHD Palliative Care Opioid Conversion Chart 
• Symptom Management

• Anticipatory crisis drugs – FWLHD Prescribing recommendations in the last days of life 
• FWLHD Medication Chart for Anticipatory Last Days of Life Medications - example
• Clinical Excellence Commission - Community Pharmacy Palliative Care Initiative

• FWLHD Subcutaneous Syringe Driver Observation Chart
• WNSWLHD NIKI T34 Syringe Driver User Guide
• FWLHD NIKI T34 Syringe Driver Use at Home Leaflet

• Provide aids and equipment
• Refer to allied health team, if required

• Provide aids and equipment
• Refer to allied health

• Initiate carer respite, if required
• Refer to home care service, if required

• Western NSW PHN Palliative Care - Services for Carers

• Refer to Specialist Palliative Care (SPC) Team
• Discuss at Specialist Palliative Care MDT Meeting
• 24/7 Palliative Care on-call service, if available

• Refer to Specialist Palliative Care Team
• 24/7 Palliative Care on-call service - Contact details sheet

• Reassess care needs at least daily
• Review care plan, in line with goals of care
• Initiate Last Days of Life Toolkit
  or Residential Aged Care End of Life Pathway

• Far West Palliative & End of Life Medical Goals of Care  
• Western NSW PHN: Factsheet for GPs – Medicare Billing in RACFs

• Visit: https://www.cec.health.nsw.gov.au/improve-quality/teamwork-culture-pcc/person-centred-care/end-of-life/last-days-of-life
• LDOL Toolkit Initiating Management Plan
• LDOL Toolkit Comfort Observation and Symptom Assessment form 

• Visit: https://www.caresearch.com.au/tabid/7015/Default.aspx
• RAC EoL Pathway form

• Communicate with patient and carer
• Provide ‘last days of life’ information leaflet

• Communicate with patient and carer – PREPARED model
• Information about the Last Days of Life 

• Confirm Preferred Place of Death (PPD) and consider transfer if appropriate
• Complete Resuscitation Plan, if not already done
• Complete Ambulance Plan, if not already done
• Complete Expected Death form, if at home and not already done

• Initiate resuscitation discussions – NSW Health PD2014_030
• Resuscitation Plan - Adult form (also on pages 22-23 of PD2014_030)
• Resuscitation Plan – Paediatric form (also on pages 24-25 of PD2014_030)

• NSW Ambulance Adult and Paediatric Palliative Care Plans

• Verification of Death and Medical Certificate of Cause of Death

• Optimise symptom management
• Discontinue non-essential medications
• Prescribe anticipatory crisis drugs and orders
• Ensure drug administration equipment in situ

• FWLHD Palliative Care Symptom Management Pocket Guide
• FWLHD Palliative Care Opioid Conversion Chart 
• Symptom Management

• Anticipatory crisis drugs – FWLHD Prescribing recommendations in the last days of life 
• FWLHD Medication Chart for Anticipatory Last Days of Life Medications - example
• Clinical Excellence Commission - Community Pharmacy Palliative Care Initiative

(CEC LDoLT) symptom management flowcharts:

• 1) Management of PAIN in the last days of life
• 2) Management of BREATHLESSNESS in the last days of life
• 3) Management of RESTLESSNESS and AGITATION in the last days of life
• 4) Management of NAUSEA and VOMITING in the last days of life
• 5) Management of RESPIRATORY TRACT SECRETIONS in the last days of life

• FWLHD Subcutaneous Syringe Driver Observation Chart
• WNSWLHD NIKI T34 Syringe Driver User Guide
• FWLHD NIKI T34 Syringe Driver Use at Home Leaflet

• Provide aids and equipment

• Provide aids and equipment
• Refer to allied health

• Refer to home care services, if required
• Provide carer medical certificates, if needed
• Identify carers ‘at risk’ of bereavement

• Western NSW PHN Palliative Care - Services for Carers

• Refer to Specialist Palliative Care (SPC) Team
• Discuss at Specialist Palliative Care MDT Meeting
• 24/7 Palliative Care on-call service, if available

• Refer to Specialist Palliative Care Team
• 24/7 Palliative Care on-call service - Contact details sheet

• Undertake verification of death
• Complete Coroner’s Checklist
• Complete Medical Certificate of Cause of Death
• Completed Attending Practitioner’s Cremation Certificate, if required
• Provide after death care

• Verification of Death and Medical Certificate of Cause of Death
  

• NSW Health Verification of Death form 

• Coroners Cases and the Coroners Act 2009 - NSW PD2010_054
• NSW Health coroners checklist form
• NSW Health report of a death to the coroner form

• Cause of death quick reference guide
• NSW Medical Certificate of Cause of Death (MCCD) - example only
• NSW Medical Certificate of Cause of Death: How to order a book of MCCD forms: https://www.bdm.nsw.gov.au/Pages/business-partners/hospitals-medical-practitioners.aspx#MedicalCertificateCauseofDeath(MCCD)form

• NSW Health Attending Practitioners Certificate

• LDoL Toolkit Care After Death

• Communicate with family and carers
• Provide bereavement information to carer

• Information about Grief and Bereavement

• Information about Grief and Bereavement
• Western NSW PHN Palliative Care – Bereavement Services
• Griefline Integrating Grief Program

• Notify healthcare professionals involved
• Wider MDT reflection and debrief, if required
• For deaths in hospital: Complete CEC death screen
• For deaths known to Specialist Palliative Care:
  After Death Discussion at SPC MDT Meeting

• Clinical Excellence Commission End of Life Program - Death Screening & Database Project