Responsibilities of Key Worker for end of life needs of their residents
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Facilitate any opportunities for Advance Care Planning
Ensure the resident and significant others needs are assessed and met, identifying any changes in the resident
Act as a main contact for the resident and significant others, liaising with other health care professionals as necessary
Ensure the resident is added to the home End of Life Register and the resident Supportive Care Plan is up to date
Identify an associate key worker to act as a deputy in their absence
1
Years to live
Holistic assessment.
MUST assessment.
Consider GP review.
If capacity, offer ACP.
Document PPC if
known or discussed.
Communication with
significant others.
2
Advanced Illness
Reassess holistic needs.
Update care plans.
Complete My Care
Plan.
ACP review.
Consider DNACPR.
Medication review.
MUST review.
Consider SALT, physio,
OT referral.
Communicate with
significant others.
3
4
Condition unstable
Last days of life
Reassess holistic needs.
Update care plans.
ACP review.
GP review – medication
review.
Consider Track and
trigger.
Anticipatory prescribing.
Obtain anticipatory
meds and equipment.
Document escalation
plan.
Communicate with
significant others.
Reassess holistic
needs update EOL
care plan.
GP review – expected
death statement.
Review medication.
Ensure anticipatory
meds and equipment
in place.
Reassess
nutrition/hydration
needs.
Communicate with
significant others and
assess their needs.
5
After death
Verification death.
Offer What Do After a
Death booklet.
Offer bereavement
information.
Inform all relevant
health professionals.
Offer support to
other residents.
Offer support to staff.
Lead reflective
debrief.