The purpose of the plan is three fold:
- A quality plan for clinical care and for organising system response to meet patient needs and goals.
- A plan that can be printed out and given to the patient and their family/whanau.
- A plan that can be shared with the local hospice so they can provide informed advice and support.
- Preparing for the Palliative Care Family/Whanau Meeting
It is recommended the Auckland Regional HealthPathways are consulted prior to the meeting. View the Adult Palliative Care pathway here
Offer and arrange a meeting with the patient and those they wish to invite, indicating it is to explore further where they are in their illness and plan towards the future.
- This would be precipitated by identifying a person requiring a palliative approach to care. The SPICT tool helps to inform clinicians about when to define a condition as palliative. Link to this tool can be found here
- The Palliative Pathway Activation (PPA) would ideally be completed about six months before the patient is expected to die. This is a broad guide only as estimating time left to live is imprecise, with significant variability. Clinicians should use their judgement and knowledge of the patient to identify the best time to have this palliative plan discussion.
- For most people preceding this meeting would be a conversation around the need for a palliative approach to their illness.
Consider the role of the GP and nurse leadership in the meeting and in preparing the plan. There is flexibility in how the meeting is managed and the plan prepared.
When inviting the patient to this meeting:
- Suggest they bring their Advance Care Plan, if they have completed one
- Suggest they think about questions and hopes or plans so an overall plan of care can be developed with them
- Ensure key clinical information is easily accessible for the discussion
- Ensure the form is prepopulated as much as possible so basic information can be checked rather than entered through the meeting.
Lead clinicians may wish to involve other members of the care team in the meeting with the consent of the patient.
Schedule about 40 minutes for the meeting (or consider 2 x 20 minute appointments). Familiarise yourself with the Care Planning Document so there is a patient-centred conversation.