1. Amber: patient’s needs changing/condition deteriorating Social situation has potential to breakdown Discharged from alternative care within 2 weeks Patient lives alone Click here Red: Patient’s condition rapidly changing/deteriorating There is a social crisis (carer breakdown) Patient is in the dying phase Click here Green: patient has palliative care needs but physical and social situations are stable Click here Somerset Desktop Navigator Palliative Care guide Identify Does the patient have a life limiting condition, or likely to be in their last year of life? Consider asking the patient if they would like to have their details added to the Palliative Care Coordination System – EPACCS (Previously known as Adastra) Specific indicators of advanced disease for patients with cancer; organ failure; and frailty and dementia, can also help. To see the GSF Prognostic Indicator Guidance click here doc 1 The ‘surprise question’ can be helpful: ‘would I be surprised if this person died in the next 12 months?’ Consent Patient consent is required unless the patient lacks capacity, in which case a best interest decision can be taken. Explain that anonymised information from the EPaCCS is used to improve services. Offer the patient the leaflet ‘coordinating my care’ 4 st interest decision can be taken EPaCCS documents Registration to use EPaCCS 2 Users guide to EPaCCS 3 Patient information leaflet 4 EPaCCS additions form 5 Useful resources: www.goldstandardsframework.org.uk www.dyingmatters.org www.nssomersetendoflifecare.nhs.ukwww.goldstandardsframework.org.ukwww.dyingmatters.orgwww.nssomersetendoflifecare.nhs.uk Link to Palliative Care handbook: 21

2. Green: patient has palliative care needs but physical and social situations are stable Discuss at monthly GSF meeting Consider offering Advance Care Planning Consider early referral to Community Nursing Patient or significant other aware of out of hours advice and response line For patients at risk of Malignant Spinal Cord Compression (especially lung, breast, kidney & prostate cancer; myeloma & lymphoma) give the patient information leaflet Word document ‘tips for successful GSF meeting’ 6 GSF Spread sheet here 7 The national leaflet ‘Planning for your future care’ can be a helpful introduction. Download only from: http://www.nhsiq.nhs.uk/resource- search/publications/eolc-planning-for-future-care.aspx 8 http://www.nhsiq.nhs.uk/resource- search/publications/eolc-planning-for-future-care.aspx The Somerset ACP document ‘Planning Ahead’ is here: 9 St Margaret’s Hospice - 0845 0708 910 (Somerset Palliative Care advice line) Weston Hospice - 01934 423912 Dorothy House Hospice - 01225 722999 Spinal cord compression patient leaflet here 10 Guide for clinicians to help make a diagnosis of malignant spinal cord compression 11

3. Amber: patient’s needs changing/condition deteriorating Social situation has potential to breakdown Discharged from alternative care within 2 weeks Patient lives alone As green, in addition: Consider DNAR status if not already addressed Link to DNAR form 12 Consider prescribing anticipatory medication Just in Case guide 13 Guidance on using MAR charts 14 Stock control forms 15 Symptom control flow charts – pain; nausea & vomiting; terminal restlessness; respiratory tract secretions; shortness of breath 16 Guidelines for opioid conversions 17 & 18 Just in Case box patient leaflet 19 If not already done, Offer ACP discussion and update EPACCS ACP Documents already listed in EPaCCS documents on front page. Can there be a link back to that?

4. Red: Patient’s condition rapidly changing/deteriorating There is a social crisis (carer breakdown) Patient is in the dying phase As Red and Amber, in addition: Ensure ACP discussion has been offered; record preferred place of death; update EPACCS; ensure DNAR status recorded Issue Just in Case medication if not already done If in dying phase, apply the 5 priorities of care, and use Somerset symptom control guidance. After death offer bereavement care and update EPaCCS Priorities for Care leaflet 20; Somerset symptom control and opioid conversion guidance documents as in amber – could this be linked? Enter date and place of death on EPaCCS and mark the note as hidden – see user guide for details 3. Update practice GSF register.