Patient identified as End Stage COPD
Initiate appropriate End of Life Care
Bundle for Respiratory Patients as
documented on the End Stage COPD
Assessment Tool for Respiratory Patients
End of Life Care Bundle for Respiratory Patients (Stage 1)
- Discuss care plan with patient, carer and
family and provide written information
- Review symptom management
- Initiate Advance Care Planning discussion
with patient/carer
- Consider referral to specialist service
- Provide information regarding benefits
(DLA/AA/DS1500)
- Inform GP that person is appropriate for
GSF Palliative & Supportive Care Register
- PPC (Preferred Priorities for Care)/ Best
Interests completed
End of Life Care Bundle for Respiratory Patients (Stage 2)
- Discuss care plan with patient, carer and
family and provide written information
- Review symptom management
- Decisions made regarding Ceilings of
Treatment and documented
- Initiate Advance Care Planning discussion
with patient/carer
- Consider referral to specialist service
- Provide information regarding benefits
(DLA/AA/DS1500)
- Continuing health care considered (<6-12m)
- Consider 24hr Rapid Discharge (<1m)
- Inform GP that person is appropriate for
GSF Palliative & Supportive Care Register
- PPC (Preferred Priorities for Care)/ Best
Interests completed
End of Life Care Bundle for Respiratory Patients (Stage 3)
- Review care plan with patient, carer and
family and provide written information
- Daily contact with patient and family
- Initiate Care Plan for the Dying Patient and
stop unnecessary investigations and
treatment
- Review referral to specialist palliative care
services and spiritual leaders
- Consider Rapid Discharge Pathway
- Update GP and Community teams by
telephone and letter
First Days After Death (Stage 4)
- Discuss with family current needs and
consider referral out to local support if
needed
- Discuss with family current needs and
consider referral out to local support if
needed
- Ensure ‘You & Your Loss’ booklet
forwarded to families
- Inform GP and hospital of death