Regulating doctors, ensuring good medical practice

End of life care: Recording and communicating decisions

  1. 75. You must make a record of the decisions made about a patient’s treatment and care, and who was consulted in relation to those decisions.
  2. 76. You must do your best to make sure that all those consulted, especially those responsible for delivering care, are informed of the decisions and are clear about the goals and the agreed care plan, unless the patient indicates that particular individuals should not be informed.
  3. 77. You should check the handover arrangements where you work, and use the available systems and arrangements for information storage and exchange, to ensure that the agreed care plan is shared within the healthcare team, with both paid and unpaid carers outside the team and with other health professionals involved in providing the patient’s care.x, xi  This is particularly important when patients move across different care settings (hospital, ambulance, care home) and during any out-of-hours period. Failure to communicate some or all relevant information can lead to inappropriate treatment being given (for example, DNACPR decisions not being known about) and failure to meet the patient’s needs (for example, their wish to remain at home not being taken into account).

 

References

x The Gold Standards Framework is one tool used to improve collaboration among care homes, GPs, primary care teams and specialist palliative care teams, and to reduce the number of admissions to hospital in the last days of life. It is available at Gold Standards Framework and at Gold Standards Framework Scotland (pdf). Teams without Walls (2008) is a report by the Royal Colleges of Physicians, Paediatrics and Child Health and GPs with advice on integrating services. See also the Out-of-hours toolkit developed by Macmillan Cancer Care.

xi Collaboration across different health and social care settings may be helped by current or planned introduction of ‘locality registers’ for patients receiving end of life care in England; e-palliative care records in Scotland; and the proposed e-record in Northern Ireland.

 

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