The green stage signifies that a patient has unstable or advanced disease. The prognosis is thought to be less than one year to months, the patient may be deteriorating month to month.
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Prognosis of less than 1 year
End of Life Care should be considered at the point (whatever the setting and diagnosis) when the person is believed to be in the last year of life. Identifying this prognosis is complex. Prognostic indicators have been suggested to support clinicians making this decision.
‘Breaking Bad News Guidelines’ have been produced to support communication. Any professional having sensitive discussions about prognosis should have recieved appropriate Communication Skills training.
In managing patients believed to be in the last year of life, the healthcare team should adopt the Gold Standards Framework for Palliative Care. The GSF focuses on seven key principles:
- Coordination of care
- Control of Symptoms
- Continuity of Care
- Continued learning
- Carer support
- Care of the dying
At this time, a Key Worker should be identified to the patient and their carers. This is a named professional who is best placed to ensure the person receives coordinated, holistic and timely End of Life Care. In Primary Care, the Key Worker is likely to be an experienced member of the Community Nursing, Long Term Conditions or Social Service Team; whilst in Secondary Care, Clinical Nurse Specialists often fulfil this responsibility.
The Key Worker should complete a Holistic Assessment to identify any unmet needs. Additionally, there should be a regular assessment of carer needs.
The outcome of these assessments will determine appropriate action including referral to other services such as specialist palliative care or long-term conditions management teams. ‘Carer Fatigue’ is a major contributing factor in hospital crisis admissions. The risk of fatigue is higher if there is a lack of appropriate and timely support and equipment provisions. Assessment should consider the range of respite care – at home or in a residential facility – and provision of assisting equipment.
Coordination of Care
The national End of Life Care Strategy recognises the importance of coordinated care. Coordination of services must exist within teams and across organisational boundaries. Methods for more effective communication between Primary and Secondary Care.
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Prognosis of less than six months
At this stage the person (regardless of diagnosis) may apply for Attendance Allowance or Personal Independence Payment under special rules using a DS1500 form. This will ensure applications are processed on a fast-track method. There should also be further assessment of the care needs of the person, with application for support according to eligibility criteria. Factual information, not a prognosis is needed for completion of the form and there is usually no need for a medical assessment. However there should be consideration that the care needs (physically, psychologically and spiritually) may have changed or be expected to change and therefore discussion and plans should be made with the patient and their family and friends to ensure needs are met throughout illness progression.
Out of Hours Care Services Provider and Ambulance Services must be informed of the patient’s current condition including details of ACP and DNACPR using EPaCCS. This information should be regularly reviewed and updated.
Carers may require enhanced support at this stage and referrals for respite care can be helpful. This may be provided in the number of ways, involving Hospice at Home, day or residential care in Hospice, Hospital or Care Home setting. The most appropriate type of respite support should be discussed and agreed with the patient, carer and health professionals.
The health and Wellbeing of Carers must be discussed and documented. A statutory Carer’s assessment should be completed by a Social Worker, if this has not already been done. A fast-track process should be used (where this is offered by the local council) for people who are in the last few months of their lives who have severe mobility problems associated with their condition and who cannot wait the two months which normal processing of the blue badge scheme applications might take.
Things to consider at this stage
Breaking Bad News Guidlines [icon name=icon-circle-arrow-right]
Fast Track Continuing Care [icon name=icon-circle-arrow-right]
Mental Capacity Act Code of Practice [icon name=icon-circle-arrow-right]
Advance Care Planning [icon name=icon-circle-arrow-right]
Lasting Power of Attorney [icon name=icon-circle-arrow-right]
DS1500 – Disability Allowance [icon name=icon-circle-arrow-right]
DNACPR – Do Not Attempt Resuscitation [icon name=icon-circle-arrow-right]