End of Life Care Plan – Community
Patient's Name: <PtFullName>
Explanatory Notes	
The End of Life Care Plan – Community has been adapted from the THS End Of Life Care Plan Inpatient Setting – Part I.  The inpatient plan was developed to be implemented when the patient is assessed as dying and death is anticipated in hours to days.  The community plan has been designed to support clinicians in the community to develop a proactive and anticipatory plan for their patients when death is anticipated in weeks to short months	
Indicators of active dying 	
•	Advanced progressive disease 
•	End stage organ failure (liver, kidney, heart, lung) 
•	Semi-conscious or drowsy for extended periods of time 
•	Decreasing/absent oral intake
•	Difficulty in swallowing oral medications
•	Essentially bed bound 	
Instructions for use 	
1.	Prior to commencing this plan, ensure the patient has a Medical Goals of Care form and Notification of Expected Death at Home form (if relevant).  These can be accessed from the Specialist Palliative Care Service or Health Pathways.
2.	This plan is designed to support decision making for care in the community.  It can be completed in conjunction with the Specialist Palliative Care Service or independently and then distributed to relevant team members.  If there are complex symptoms and/or uncontrolled symptoms, please contact the Specialist Palliative Care Service.  
3.	The plan may be developed with the patient and/or their family as appropriate. 
4.	Regular clinical reviews and clear communication are vital to ensure high quality care for both the patient and family.  
5.	Review is flexible according to the needs of the patient – it may need to be fortnightly, weekly or more frequently as appropriate.  	

End of Life Care Plan – Community

GP Chronic Condition Management Plan (MBS item number 965)	

Patient information	
Name	<PtFullName>	Date of birth	<PtDoB>	
Address	<PtStreet>	
Suburb	<PtCity>	Postcode	<PtPostcode>	
Medicare card 	<PtMCNo>	Private Health	<PtHealthIns>	

Details of Patient’s usual GP	
Name	<DrName>	
Practice name	<Practice>	
Address	<UsrAddress>	
Contact after hours	
Mobile number	<Patients usual GP - mobile number> <DrMobilePhone>	
I would like to be contacted after hours for this patient in the event of deterioration/death 	<GP can be contacted A/H for deterioration/death?>	
I am happy to be contacted for a death certificate but would like the Specialist Palliative Care after-hours service to authorise DOLE 	<Call GP for death cert - but Pal Care A/H for DOLE>	

Contact information for family/carer	
Primary contact person	
Name	<Family/carer -Primary contact name>	
Relationship to patient	<Primary contact relationship to patient>	
Phone number	<Primary contact phone number>	
Contact availability	<Primary contact availability by phone>	
Staying with patient overnight?	<Primary contact staying with person overnight>	
Secondary contact person	
Name	<Family/carer - Secondary contact name>	
Relationship to patient	<Secondary contact relationship to patient>	
Phone number 	<Secondary contact phone number>	
Contact availability	<Secondary contact availability by phone>	
Staying with patient overnight?	<Secondary contact staying with person overnight>	

Date of last Care Plan/GP Management Plan (if done):	<Date of last Care Plan/GPMP (if done)>	

Other notes or comments relevant to the patient’s management plan: 	
<Other notes relevant to the pt's management plan>	

Past Medical History (Associated Comorbidities)	
<SelectedPMH>	

Primary Diagnosis	
Initial symptom assessment 	Symptoms present
please X to select	

Yes	
No	

	PRN medication comments
please detail below	
Pain 				
Agitation				
Confusion/delirium				
Dyspnoea				
Nausea and vomiting				
Respiratory secretions				
Swallowing Difficulties 				
Constipation/bowel problems				
Bladder problems/IDC				
Conscious				
Emotional distress				
Anxiety				
Sleep disturbances				
Seizures				
Ascites				
Risk of significant haemorrhage (GIT, haemoptysis, wound)				
Other *(specify)				

Family History	
<FamilyHx>	

Medications	
<SelectedRx>	

Allergies	
<Reactions>	

Advance Care Planning Documentation	Yes	No	
Copies have been reviewed and are in the medical record			
Advance care directive			
Enduring Guardianship			
Body Bequest			
Organ and tissue Donation			

Communication	Details	
Is the patient able to participate in the discussion? 
(Yes/ No)		
If ‘No’, describe why they are unable to participate
(e.g. conscious state, hearing impaired, intellectual impairment, cognitive impairment, neurological condition)		
Does the patient understand they are dying?
(Yes/ No)		
Preferred place of care?
(Home, hospital, district hospital, palliative care unit, RACF)		
If unable to participate, discussed with?
(family/ carer/ enduring guardian)		
What is important for the family at this time?
(please provide details)		
What is important for the patient and family after death?
(please provide details)		
Who else do you want us to share information with?
(please provide details) 		

GP Chronic Condition Management Plan – End of Life Care (MBS item 965)	

Consent	
I have explained the steps and any costs involved, and the patient has agreed to proceed with the plan 	
GP name	<DrName>	
GP signature 		Date	<TodaysDate>	

Patient problems / needs / relevant conditions	Goals - changes to be achieved	Required treatments and services including patient actions	

Yes	
No	

	Arrangements for treatments/services (when, who, and contact details)	
1. Medication Review	Review medication and rationalise as appropriate	Has the non-essential medication been discontinued?	

Appropriate oral medication converted to subcutaneous route 	

	- GP
- Pharmacist 
- Specialist Palliative Care Service	
2. Review of current interventions 	Continue appropriate interventions as per the person’s wishes or medical indication. 

These interventions are those available in the community only	Routine blood tests 	

Intravenous antibiotics 	

Intravenous fluids	

Intravenous medication	

Oxygen 	

Artificial/Enteral feeding 	

Renal replacement therapy 	

X-rays 	

Routine vital signs/monitoring 	

Blood glucose monitoring 	

Anticoagulant therapy/VTE prophylaxis 	

Pressure injury/wound management1 	

1consider odour, exudate and pain	

	- GP
- Specialist Palliative Care Service 
- Oncologist 
(if appropriate)

Make notes of rationale if relevant here:	
3. Symptom control	Manage symptoms 
Keep comfortable 	Initial symptom checklist – review if changes 
Review of current interventions
Medication guidelines (appendix 2)	- GP 
- Patient/Family
- Community Nurse
- Oncologist 
- Specialist Palliative - Care Service 
- Other:	
4. Psychological support
	Support for patient and family	Help patient and family to manage anxiety, anger, depression, and /frustration. 
Medication management 	- GP 
- Counsellor
- Psychologist	
5. Religious/ spiritual support	Patient / family receive support required	Access to support	- Religious adviser	
6. Social support	Organise support services to assist patient / family	Home help
Shopping
Respite
	- GP
- Community nurse
- Local Council
- Home help
- Other community services	
7. After Hours Support	Communicate support for patients after hours	Provide a copy of this plan to Specialist Palliative Care Services
NW: palliativecareservicenw@ths.tas.gov.au
N: palliativecare.north@ths.tas.gov.au
S: pcsouth@ths.tas.gov.au	- GP 

GPCCMP Documentation	Yes	No	
Copy of GPCCMP offered to patient?			
Copy/ relevant parts of the GPCCMP supplied to other providers?			
GPCCMP added to the patient’s records?			

Date service was completed:		Proposed Review date:		
Life Care (MBS item 721) Management Plan – End of Life Care (MBS item 721)
Appendix 1 – Team Member Summary (as relevant)	

Provider 	Role of service	
Specialist Palliative Care Service		
Local pharmacy 
(?ComPPaCT participating)		
Community Nursing 		
RACF/Supported Accommodation		
Allied Health 
•	Social Work 
•	Counselling 
•	Psychologist 
•	Physiotherapist 
•	Occupational Therapist 		
Other services 
•	Aboriginal Health Liaison Officer
•	Multicultural Liaison Officer
•	Pastoral Care
•	Palliative Care Volunteer 
•	Grief and Loss Service 		
DonateLife		
UTAS		
Other 		

Appendix 2 – Palliative Care Medication Guidelines	

Anticipatory prescribing aims to ensure that patients will receive optimal symptom control during end of life care. 

Review opioids/benzodiazepines/dose/frequency for patients who are elderly, frail, cognitively impaired or have renal failure. 	
If Syringe Driver (Continuous Subcutaneous Infusions – CSCI) required – considerations when commencing:	
Syringe driver can contain up to 4 drugs and provides background medications.  Takes up to 6 hours to establish clinical effect.  Syringe driver dosing considerations:
•	Incorporation of patient’s current regular analgesics / benzodiazepines / antipsychotics / antiemetics if appropriate
•	For example, MS Contin 10mg BD = Morphine 10mg subcut over 24 hours (dose conversion appropriate for end-of0life care; not for general application)
•	Conservative dosing in frail/elderly
•	Common starting dose for uncomplicated dying is Morphine 10mg / Midazolam 10mg subcut over 24 hours 
•	Contact the Specialist Palliative Care Consultant on-call if advice needed on syringe driver/medication commencement and/or titration 	
PRN Medications 	
•	Must be charted with commencement of syringe driver 
•	PRN dosing of analgesia is usually at least 1/6th of the 24-hour total syringe driver dose 	
First Line Drug Considerations	
Drug	PRN Dose	Clinical Indications/s	
Morphine (titrate to effect)	2.5 to 5mg subcut one hourly	Pain / dyspnoea / cough	
Midazolam 	2.5 to 5mg subcut one hourly max 60mg/24 hours 	Dyspnoea / distress / anxiety	
Haloperidol	0.5 to 1mg subcut four hourly max 5mg/24 hours	Delirium / nausea / vomiting / hiccups	
Glycopyrronium bromide (glycopyrrolate)
OR
Hyoscine butylobromide	400 microg subcut two-four hourly max 1200microg/24 hours

20mg subcut two hourly max 120mg/24 hours	Upper respiratory secretions	
Second Line and Other Drug Considerations	
Drug	PRN Dose	Clinical Indication/s	
HYDROmorphone 
(5x stronger than morphine)
(use in renal impairment)	0.5 to 1mg subcut one hourly 	Pain / dyspnoea / cough 	
CLONazepam 	0.5 to 1mg subcut four hourly max 4mg 24/hours	Anxiety / distress (not used in syringe driver)	
Metoclopramide	10mg subcut TDS 	Nausea / vomiting / hiccups	
Cyclizine	25 to 50 subcut TDS	Nausea / vomiting	
History of Seizures/ Regular Anti-epileptic Medications for Seizure Prophylaxis 	
Drug	Regular Dose	Clinical Indication/s	
CLONazepam 	0.5 to 1 mg BD subcut regular 	No recent history of seizures, on regular anti-epileptic medications	
CLONazepam 	1 to 2 mg BD subcut regular	Recent history of seizures, on regular anti-epileptic medications	
Additional Clinical Considerations	
For patients on long term oral benzodiazepine and unable to swallow, consider commencement of regular subcut CLONazepam or replace with midazolam via syringe driver. 
Haloperidol/metoclopramide should not be used in Parkinson’s disease. 
Catastrophic orders (for example, risk of haemorrhage) consult with the Specialist Palliative Care Team
Oxygen is generally not used in the community – discuss with Specialist Palliative Care Team
Type 1 Diabetes – continue long acting insulin at reduced dose (aim BGL 6-15 mmol/L until unconscious.
Type 2 Diabetes - insulin / oral hypoglycaemics and monitoring of BGL can be ceased unless symptomatic and BGL >15mmol/L 
For information regarding compatibility combining medications in syringe drivers – Eastern Metro Palliative Care Consortium – Clinical Guidelines – Syringe Driver Drug Compatibilities 
https://www.bettersafercare.vic.gov.au/clinical-guidance/palliative/syringe-driver-compatibility 	

Abbreviation Key: BD twice daily | BGL blood glucose level | GIT gastrointestinal tract | IDC Indwelling Catheter | mg milligrams | microg micrograms | mmol/L millimoles per Litre | PRN as required/when necessary | subcut subcutaneous | TDS three times a day | VTE Venous Thromboembolism