What can my organisation do?
Provide clients and residents with options for responses to an emergency. They can be documented in an Advance Care Plan (ACP) or Advance Care Directive (ACD).
Ensure that all clients have the opportunity to document their preferences for end-of-life care and that this is updated if there is a significant change in their condition.
Before organising a hospital transfer for a client or resident, ask their preferences or consult their ACD or ACP.
- contact details of substitute decision-makers are clearly documented (and reviewed regularly)
- an Advance Care Plan (ACP), Advance Care Directive (ACD), "not for resuscitation" (NFR) orders, "do not attempt resuscitation" (DNAR) orders are easy to find in notes, records and the goals of care
- care plans are regularly reviewed.
A system for uploading ACP documents may assist accessibility by various people and organisations which provide care; My Health Record may be useful.
Ensure that discussions about futile care are routine in your organisation and that they are scheduled early, preferably when the client or resident is able to participate.
Train careworkers to be comfortable talking about death and make them aware that nurses can deliver palliative care in the home to enable them to support clients and families.
Consider a nurse practitioner model so that nurses have an experienced and available resource to call upon for advice and prescribing.
Consider implementing a formal bi-annual medication review for clients and residents.