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									                                   Planning Ahead Guide
                         Advanced Chronic Disease including Dementia
   This model advocates for a ‘Multidisciplinary Team’ approach that focuses on dignity and comfort, prevents
   futile treatment decisions and openly engages in quality of life discussion and care planning for a natural death.

                  Registered                      General                     Care and                 Person /Person
                Nurse / CNS                     Practitioner                Lifestyle Staff             Responsible
                Social Worker                   Geriatrician
                Practice Nurse                    Specialist                Allied Health                Family and
                  CNC / NP                     Palliative Care                 Workers                    Friends

                                 Consensus Model of Care Planning for End of Life
                                         Multidisciplinary Team (MDT)

    Prognostication                Legal and Ethical                Advance Care                     End of Life
                                         (NSW)                      Planning (ACP)                     (EOL)

    Does this person have           Identify the Person              Provide reading              Conduct a medication
     an advanced chronic            Responsible hierarchy:        materials / information          review – cease futile
     disease or dementia?           1. Enduring guardian           about Advance Care                   medication
       (Refer: to relevant          2. Current spouse                Planning (ACP)               Assess pain score and
    literature & resources          3. Current carer                                              document appropriate
     i.e.: UWS Dementia                  (non- professional)                                     pain management regime
                                    4. Family / friend            Hold an ACP meeting /
        Trajectory Chart)
                                                                    case conference with
                                                                      person / person
                                                                                                  Review Advance care
                                                                   responsible, other key
    Does this person have           Explain role: Advocate           family members &            Plan (ACP) for guidance
                                     for making decisions                                         in End-of-Life (EOL)
    prognostic indicators?                                         multidisciplinary team
                                      that person would                                             care and treatment
   (Refer: Prognostication
   Indicator Guide (PIG)              have wanted if they
   Tool or Medical Orders           could decide them self         Record discussions life
      for Life Sustaining            This may not always be        choices as an Advance          Commence End of life
    Treatment (MOLST)                 what the family wants.         Care Plan (ACP)
                                                                                                 Pathway and review care
                                                                                                     plan with family
   Discuss treatment goals           Complete MOLST
   for this patient.. Is there        Sign off by GP &                 Review ACP &
                                                                    MOLST at any change           Thorough assessment
   common understanding              Person Responsible
                                                                   in condition, refer back      and management of any
   of curative and comfort
                                                                      with the person or           End-of-Life (EOL)
     goals of treatment?
                                                                    person responsible to          symptoms prioritise
                                     Copy MOLST onto                                              comfort care choices
                                    bright green paper and           confirm agreed plan
     Surprise Question               place in visible place          when situations arise
   Would you be surprised            within persons aged
   if this person was to die        care facility notes or in
      within the next 6-12             a plastic sleeve in
            months?                     persons home.
                                                                                                    Identify complex grief
                                                                                                  and refer to support - i.e.:
Consensus building model for End-of-Life decision making - August 2011 – JC/HCPDCF - Version 4          pastoral care

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