CEG 049/16 A
The Nottinghamshire Priorities for Care
A Personalised Plan of Care for the Last Days of Life
Version 1, March 2016. Review due March 2019.
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
1/6
View the summary of the Priorities for Care at www.epaccs.co.uk
Initial Assessment
Name
Role
Signature
Date
Priority 1 – Recognise
Recognise the possibility that death may occur in the next days or hours
1.1 Consider within the MDT why the patient is thought to be dying.
Ensure a doctor has reviewed the patient to exclude all reversible causes.
Record name of this doctor
1.2 Explain that death is a possibility and likely prognosis to the patient and those important to them
Record what has been explained and to whom.
1.3 Have you Informed the patient and those important to them which doctor and nurse are
responsible for their care?
Yes / No
Record name of responsible doctor
Doctor’s Name
Record name of responsible nurse
Nurse’s Name
1.4 How much does the patient wish to be involved in decisions about their care?
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
View the summary of the Priorities for Care at www.epaccs.co.uk
2/6
Priority 2 – Communicate
Communicate with patient and, with consent, those important to them, in an open, honest and sensitive
manner
2.1 Record any communication difficulties and action taken if necessary
2.2 Record with whom (family members/those important to them) the patient wishes information to be
shared
2.3 Discuss or check previous stated wishes are up to date
Preferred Place of death
Wishes following death
Have you discussed common symptoms in the final days?
Yes / No
Discuss how to seek help, who to contact in the event that the patient’s condition suddenly changes or
what to do when patient dies. Record this information here
2.4 Openly discuss, address and record any differences of opinion on care the patient or those
important to them have
Ensure the responsible doctor and nurse are aware of these discussions and if necessary offer a second
opinion
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
3/6
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Priority 3 – Involve
Involve the patient and those important to them in decisions about their treatment and care
3.1 Does the patient have an Advance Statement of Wishes? If yes record the detail
3.2 Does the patient have an Advance Decision to Refuse Treatment? If yes record the detail
3.3 Does the patient have a Lasting Power of Attorney for Health and Welfare?
If yes are they registered with the office of public guardian?
Record evidence
If yes, record the LPA and their contact phone number
What decisions can they make
3.4 DNACPR Status
Please record the patient’s resuscitation status
For Resuscitation / Not For Resuscitation
Has this been recorded in all appropriate places (e.g.
Systm one EPaCCS )
Yes / No
Where is the DNACPR form? (E.g. Nursing folder
with patient)
3.5 Anticipatory Medication
Is this prescribed and are all medicines in the home?
Yes / No
Please record location or any other important details
3.6 Actively review and record whether other interventions e.g. PEG feed, ICDs need to be continued,
adjusted or stopped
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
View the summary of the Priorities for Care at www.epaccs.co.uk
4/6
Priority 4 – Support
Assess the needs of and support the family and those important to the patient
4.1 Discuss, record and address the needs or concerns of family and those important to the patient
4.2 Do the family and those important to the patient require any additional practical support or
referrals onto other agencies? If yes, please record what has, or needs to be, referred on to other
services
4.3 Are there children or vulnerable adults in the household. If yes, what support is in place to meet
their needs?
4.4 Ensure that the patient, family and those important to the patient have contact details for all
services involved in the patient’s care. If not, record what action has been taken
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
5/6
View the summary of the Priorities for Care at www.epaccs.co.uk
Priority 5 – Plan and Do
Side 1/2
Aim to have an individualised plan of care prioritising
communication, comfort and dignity
5.1 Symptom Control - Physical
Identify and record physical
symptoms
Record their management and action
taken if symptoms are not controlled
5.2 Symptom Control - Psychological
Identify and record psychological
symptoms
Record their management and action
taken if symptoms are not controlled
5.3 Medication
Non-essential medication stopped?
Yes / No
Record what medication patient is
still taking (name, strength,
formulation, dose, frequency)
Have you discussed with patient/ family/ those important to them rationale of
medication changes?
Yes / No
Record summary of discussion
Record what you have discussed about method of medication administration and potential effects of
medication
Are there adequate quantities of anticipatory and ongoing medication in place?
Yes / No
Patient Name
NHS Number
Priorities for Care of the Dying Person – Initial Assessment
View the summary of the Priorities for Care at www.epaccs.co.uk
Priority 5 – Plan and Do
Aim to have an individualised plan of care prioritising
communication, comfort and dignity
5.4 Social and Spiritual Needs
Identify and document any social,
spiritual, religious or cultural needs
Identify and document specific
requirements after death if any
5.5 Nutrition and Hydration
Record discussions with patient/
family / those important to them
5.6 Care Needs Have you addressed the following care needs? Please record action taken
Mouth care
Pressure ulcer prevention
Management of bladder/bowels
Equipment requirements
5.7 Bereavement
Are plans are in place for care after
death
6/6
Side 2/2
Patient Name
NHS Number
Priorities for Care of the Dying Person –Ongoing Daily Assessment
1/2
View the summary of the Priorities for Care at www.epaccs.co.uk
Ongoing Daily Assessment
Name
Role
Date
Signature
6.1 Symptom Control - Physical
Identify and record physical symptoms
Consider pain, nausea, breathlessness, respiratory
secretions, agitation, etc.
Record their management and action taken if
symptoms are not controlled
6.2 Symptom Control – Psychological/Spiritual
Identify and record psychological symptoms
/spiritual needs
Record their management and action taken if
symptoms are not controlled
6.3 Medication
Record any medication changes and inform
patient/those important to them of rationale.
Are there adequate quantities of anticipatory and ongoing medication in place?
Yes / No
Patient Name
NHS Number
Priorities for Care of the Dying Person - Ongoing Daily Assessment
View the summary of the Priorities for Care at www.epaccs.co.uk
2/2
6.4 Nutrition and Hydration
Record any changes in requirements, action taken and discussion had with patient/ family / those
important to them
6.5 Care Needs
Have you addressed the following care needs? Please record action taken
Mouth care
Pressure ulcer prevention
Bladder/bowel
management
Equipment requirements
Is patient still felt to be in the last few days of life?
If no please record further action taken and discussions
Yes / No
Patient Name
NHS Number
Priorities for Care of the Dying Person Extension Sheet
Ongoing Evaluation and Progress Notes
Date and
Time
Further record ongoing clinical review
e.g. significant events / conversations / visit by
other specialist teams e.g. palliative care /
second opinion if sought
Name and Role
Signature
Patient Name
NHS Number
Priorities for Care of the Dying Person Extension Sheet
Ongoing Evaluation and Progress Notes
Date and
Time
Further record ongoing clinical review
e.g. significant events / conversations / visit by
other specialist teams e.g. palliative care /
second opinion if sought
Name and Role
Signature