ผลกาปฏิบัติงานทีป็นลิศ ( Best Practice · ผลกาปฏิบัติงานทีป็นลิศ (Best Practice) ๑. หน่วตวจสอบภาน
Best Practice in End of Life Care:
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Transcript of Best Practice in End of Life Care:
Best Practice in End of Life Care:
Gold Standards Framework in Community Hospitals Programme Jo Smith
- End of Life Programme Facilitator Ally Hardman Locality Director
& End of Life Care Lead Aims of Gold Standards Framework in
Community Hospitals
Quality of care to improve the quality of care provided for all
patients approaching the end of life and improving their experience
of care Coordination to improve the coordination and collaboration
of care within and between teams and across boundaries to ensure
seamless care through improved organizational change. Outcomes to
improve patient outcomes, reduce acute hospitalization in the final
stages of life and enable more to live well and die well in their
preferred place of care. Accreditation Process
There are 4 parts to the GSF Accreditation Process: Outcome
measures summary of key outcome ratios evidence of attainment of
standards in key areas Audit Patient After death analysis (5 deaths
+ 5 discharges) Staff confidence & competency Organisational
attainment of key changes Portfolio of evidence demonstrating
attainment of the 5 standards plus patient case study &
evidence of patient / carer feedback Assessment 3 hour ward
assessment visit from the national GSF assessment team The Five GSF
Gold Standards
Right people identification of patients nearing the end of life
Right care assessing their needs: clinical & personal Right
place planning coordinated cross boundary care Right time planning
care in the final days Every time embedding consistent good
practice and identifying areas to improve further Right people
identifying the right patients
Are we identifying the right patients & recognizing them early
enough? Identify on admission, identify whether the patient may be
in the final year of life Code use needs based coding and plan
pro-active care with core care plan (needs support matrices) to
give right care at right time Discuss at regular multi-disciplinary
team meetings the patients progress and pro-active care for the
appropriate GSF code. Review regularly, recode as needed and review
weekly as a minimum GSF - Core Care Plans To give pro-active care,
ensuring that appropriate care is being co-ordinated to meet the
needs of the patient To give the patient the opportunity to discuss
their wishes and preferences To ensure effective communication
& collaboration across care settings takes place aligned with
the patients needs Right Care assessing their needs clinical &
personal
Do we really know the patients and carers needs, wishes and
preferences for care towards the end of their life? Assess clinical
needs clinical assessment using holistic approach and referral as
needed to appropriate specialist services Assess personal needs
Advance Care Planning discussions: offer ACP discussion: (as
capacity allows, best interests always considered) Initial
introductory conversation and information leaflet Discussion of
resuscitation status, preferred place of care and proxy
spokesperson, LPA Full ACP discussion initiated and recorded Assess
carers needs: informal carers and family are offered an assessment
and are signposted and given appropriate support Advance Care
Planning Umbrella term for the voluntary process of planning ahead
for possible healthcare decisions Enables communication of wishes,
views and preferences Usually in the context of an anticipated
deterioration in the individuals condition and/or changes to
capacity The Treatment Escalation Plan (TEP) and Resuscitation
Decision Record
Documentation of plan of care for patients and whether they are for
or not for cardiopulmonary resuscitation Focus around the process /
discussions with patients / families / carers Adoption of one form
across all of Cornwall's health community ensures continuity of
care approach Right Place planning coordinated cross boundary
care
Living Well: are we planning across boundaries? Plan community
support and care to reduce avoidable crises and readmissions
Communicate with receiving healthcare team / GP the needs based
code and recommended actions and progress of advance care planning
Discharge planning rapid discharge / fast track with appropriate
follow up and referral in the community. Right Time planning care
in the final days
Dying Well: are we enabling care aligned to patient preferences in
the final days? Care in the final days using five priorities of
care guidance individual end of life care plan Anticipatory
prescribing Cornwall anticipatory prescribing guidance Nominated
clinician Care after death -including providing support and
understanding to the deceaseds family and significant others
throughout all stages. Individual End of Life Care Plans
Sensitive communication with the dying patient and those identified
as important to them Support of family members and those identified
as important to the dying patient Symptom control Food and drink
Spiritual and religious care Every time embedding consistent good
practice
How will we sustain and build on these improvements to ensure we
provide consistent high quality care for everyone of our patients
nearing the end of life? compassionate care with dignity and
respect for all patients /families regular audit and review weekly
GSF key ratio outcomes staff training & education annual
appraisal submission to the GSF national team How do our patients
benefit?
Physical symptoms are anticipated and reduced where possible,
before they cause problems They feel they have some choice and
control and that choices around preferred place of care are
discussed and recorded They feel supported and informed and that
potential problems are anticipated and reduced. This includes from
admission right up to discharge. Their family or carers feel
enabled, informed and involved in their care and are supported as
much as possible. Any Questions?