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Palliative Care Clinical Care Programme

Rapid Discharge Planning Pathway. Palliative Care Clinical Care Programme. To facilitate a safe, smooth and seamless transition of care from hospital to community for persons who have expressed a wish to die at home. What is the aim of RDP?.

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Palliative Care Clinical Care Programme

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  1. Rapid Discharge Planning Pathway Palliative Care Clinical Care Programme

  2. To facilitate a safe, smooth and seamless transition of care from hospital to community for persons who have expressed a wish to die at home. What is the aim of RDP? Published 2013 Version 1

  3. Driven by the wishes of the person and their family/carer. When a clinical situation has changed and there is an urgent request to enable the person to die at home. Part of HSE Integrated Discharge Planning. What is the rationale for rapid discharge planning (RDP)? Published 2013 Version 1

  4. To: Support the wishes of the person and their family/carers. Provide a framework for collaborative working across primary and secondary care. Support effective communication between all key stakeholders. Facilitate the involvement of appropriate professionals to coordinate the continuing care. What is the purpose of the RDP document? Published 2013 Version 1

  5. Who does the RDP involve and concern? • All health and social care professionals working in the HSE and in any organisation providing services on behalf of the HSE. • People affected by the guidance i.e. service users and their families/carers, and the general public. Published 2013 Version 1

  6. What are the steps in RDP process? The Person chooses to die at home Step 1 Step 2 Doctor confirms it is appropriate and the Family/ Carer support CNM identifies Lead Nurse to coordinate Step 3 Lead Nurse implements process Step 4 No anticipated post mortem or organ donation Lead nurse leads on implementation of RDP action plan Doctor documents in person’s notes Lead nurse identified from person’s ward/unit Published 2013 Version 1

  7. Contact GP, PHN/DoN and other members of the primary care and/or specialist palliative care team as soon as possible. What does the Lead Nursedo? Contingent on certain supports/ services Poses a clinical risk to safety or well-being The GP and PHN /DoN: may confirm that rapid discharge is appropriate Rectify and proceed or Rectify and proceed or Proceed with plan Unable to rectify, abandon and discuss with patient, family and team Published 2013 Version 1

  8. What are the next arrangements to implement? Within 24 hours before discharge: • Ambulance • Liaise with Ambulance Service re: • Transport arrangements • Ambulance letter • Primary Care Team • Liaise with GP/PHN/DoN • Develop care plan • Liaise with MDT • Fax copy of prescription to • GP & community pharmacy • Equipment • Organise equipment • Medical supplies • Write nursing discharge • letter • Family • Support family • Clarify expectations • Provide carer education Published 2013 Version 1

  9. Liaison with Hospital/Community MDT Physiotherapy Dept: As appropriate • Medical Social Work • Dept re: • Assessment and addressing • of psychological needs • Essential practical needs • Community Pharmacy re: • Unlicensed meds • Meds difficult to source • Meds not on GMS OT Dept re: Essential equipment Published 2013 Version 1

  10. What are the considerations when planning with CNS in Palliative Care? • Is Night Nursing Service required? • Is Community Specialist Palliative Care Team (SPCT) required? • Advise re complex needs for potential symptoms Published 2013 Version 1

  11. What is the role of the NCHD in RDP planning? The NCHD will: • Write discharge letter. • Write prescriptions - regular medications/p.r.n. medications (24 hours prior to discharge). • Contact GP re verifying and issuing the certificate of cause of death. • Complete section in ambulance service letter. Published 2013 Version 1

  12. What are the Final Actions? SPCT On discharge: Letters to: • GP, • PHN/ DoN • SPCT • Other member of the primary care or specialist teams as appropriate. • Letter to Ambulance Service including DNAR order as appropriate. Syringe pump: • Change immediately prior to discharge if in use. Prescriptions: • Hand to family unless transferring to residential care facility. GP PHN /DoN Ambulance Published 2013 Version 1

  13. What information can I find in the RDP Document? • Detailed outline of rationale and process. • Outline of roles and responsibilities. • Information regarding actions when anticipated post mortem is anticipated or agreement for organ donation. • Useful links to resources. • Useful suggested templates and flow-chart of process. • Frequently asked questions. Published 2013 Version 1

  14. Please visit: www.hse.ie/palliativecareprogrammeto download RDP document and for further information on the HSE Palliative Care Clinical Care Programme. Published 2013 Version 1

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