1. West Essex Frailty Pathway: Principles of End of Life
Recognition
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Advance Care Planning
Discussions with patient involving relevant primary care/community teams
Link worker assigned
Care Plan written
Including documenting PPC,PPD and DNAR
All relevant agencies identified and information is shared
Care is coordinated through coordination centre. Relevant fast track processes commenced for funding when required.
Key worker acts as link to all agencies.
Key worker can ensure care plans are updated.
Care delivery including ;
Providing support for last few weeks or days of life in accordance with PPC and PPD
Care after death
Bereavement support and follow up for families and carers.
Single Point of Access (SPA) 08:00-21:00, Seven days a week
Telephone: Fax: