4. Care planning

Care planning establishes the care goals and needs of the person, their family and carers. Individuals should be involved as much as possible in their care planning, to ensure their preferences and needs are reflected. Recognising variation in community and cultural preferences and expectations of care will help to support a person-centred approach for all. Multicultural health and Aboriginal health professionals can provide cultural guidance and support and, where applicable, be part of the multidisciplinary team.

Action

Processes are in place to ensure that following comprehensive assessment of people with life-limiting illnesses, the person, their family and carers are actively involved in discussions and decisions regarding immediate care needs and advance care planning.

Appropriate documentation must reflect these decisions.

Evidence

Care planning is important to support meeting the goals and needs of the person with life-limiting illness, their family and carers.

Considerations and resources

Advance care plans must be readily available for current and future care providers, including during unplanned and out-of-hours care (including formal documents, such as advance care directives).

Advance care planning information and resources are available on the NSW Health website and tools such as the End of Life electronic medical record (eMR) solution can improve shared care planning across multiple settings.

Care plans need to be communicated with the person’s general practitioner and original referrer.

Processes must be in place to ensure periodic reassessment of patient and family/carer needs, as these needs may change over time. This includes the provision of relevant health literate information.

Using virtual care

Referrers should consider the questions and use the tools and information below when providing virtual palliative and end-of-life care.

If in-person assessment is not required, which available virtual care modality will provide the highest quality assessment? Be aware that 55% of communication comes from facial expressions and body movement. More on ways of delivering virtual care.

Has the patient’s preferred place of death been discussed with them, their family or carer? If not, is this the appropriatetime to commence the discussion and planning? If the patient expresses that they prefer to be at home for their end of life, inform them about how virtual care can support their decision.

Does the patient, family or carer need support to navigate the virtual care platform? Consider the need for an additional clinician, family or carer to be available to support the patient. Provide virtual care education resources as required.

Who else needs to attend the appointment? Any person who can support the patient can be included in a virtual consultation with their consent. If the patient does not have decision-making capacity, is the person responsible attending the appointment? Is a support person needed? Has the patient identified a family member/carer to be included in their care discussions? Has the clinician considered the multidisciplinary advantages of having the GP, family, specialist, other health professionals and other relevant people to attend the appointment?

What happens if the patient, family, or carer deteriorates, or the technology fails while I’m providing care virtually? Each team should have its own protocols for escalating care or managing technology failures during an appointment.

Measures could include:

• Confirming the patient’s address and contact number at the start of any consult
• Being able to call an ambulance or other emergency service
• Organising an urgent visit
• Contacting a family member
• Enacting the backup process if the connectivity is poor or the technology fails

More about consumer support

For more virtual care resources, see:

• Virtual care in practice guide
  Information to support healthcare providers to deliver virtual care.
• Virtual care palliative care resources for clinicians and consumers
  Resources supporting health professionals, patients, families and carers to access and use virtual care as part of palliative care.

Video resources