Section 4
‘Planning for the Future Project’ St Vincent’s Hospital, Athy, Co. Kildare (16) This project commenced in 2010 and aimed to develop a framework to support staff with initiating discussions around end-of-life care issues with residents and families in Le Cheile (dementia specific unit) and was funded by the IHF. The interim report on this project was published in Sept 2013. One aspect of the project was the development of an end-of-life care form with accompanying guidance, which is available on the IHF website. See below for adapted content.
End-of-life care form (Adapted from St. Vincent’s Athy)
Planning for End-of-life Care Form Before completing this form, please refer to page 2.
It is really important to us that we care for you in the way that you want to be cared for. We want to make sure that any decisions about your end-of-life care and treatment both now and in the future are based on your values, wishes and preferences. 1) We want you to remain as well as possible for as long as possible but have you ever thought about what would be most important to you if you became seriously ill while you are in St Vincent’s? _________________________________________ _________________________________________ If the doctor and staff felt that acute treatment in a general hospital would not be of benefit to you at that particular time, what would you prefer to do? 2) Remain in St Vincent’s hospital for treatment and symptom management Yes No 3) Transfer for more advanced acute medical treatment to Accident and Emergency department. Yes No ALL DECISIONS ABOUT YOUR ONGOING MEDICAL CARE WILL BE MADE IN CONSULTATION WITH YOU AND YOUR DOCTOR, AND IN YOUR BEST INTEREST. 4) You might find discussing end of life care difficult, in which case could I ask you to think about your wishes and preferences around future end of life care and I will back to you again on Nurse’s Signature ________________________ Date ___________________ 5) Are there any documents we should be aware of in relation to your end of life care e.g. Enduring Power of Attorney (EPA)/Ward of court? Ensure relevant information is documented and updated in residents medical notes
6) Can you tell me what you understand about your illness and this particular stage of it? ______________________________________________ ______________________________________________ 7) What do you think would be most important to you when you are nearing end of life? E.g; Have you ever through of where you would like to be? Who would you like to have with you? ______________________________________________ ______________________________________________ 8) Would you like to talk about worries or fears that you may have about death and/or dying? ______________________________________________ 9) Any preferences/wishes for after death? 10) Wish to be Cremated: Yes No 11) Have you shared any of this information with your family, friend or any other person? Yes No With _________________________________________ Relationship _________________________________ 12) Would you like to share this information with your other relatives or friends? Yes No We will give you the opportunity every three months (or sooner if there is any change in your condition), to revisit these discussions. This will allow you to add to, or change any preferences and wishes already discussed. Information obtained from ______________________________________________ Relationship: __________________________________ Care Plan Commenced: Yes No Date _______ Palliative care Plan: Yes No Date _______
Nurse’s Signature __________________ Date _______
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Facilitating discussions on future and end-of-life care with a person with dementia
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