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Managing Crises - Practice Points

What we know

A crisis or an emergency in palliative care is a sudden deterioration in a person’s condition which requires an urgent response. The response to a crisis towards the end of life will depend on the person’s overall condition, their wishes or those of the appointed substitute decision maker(s). Pre-emptive end-of-life care discussions can ensure care is delivered in line with a person’s wishes including what to do in an emergency. These discussions may also be helpful in putting appropriate supports in place. Anticipatory prescribing may allow prompt symptom relief and avoid distress or a crisis.

What can I do?

Use the SPICT Tool to identify people whose health is deteriorating so that care can be planned proactively. SPICT4ALL can also be used by people who prefer less ‘medical’ language.

The End-of-Life Essentials checklist (141kb pdf) is also useful.

Talk to people early while they are able to make decisions and their condition is stable, about how to manage unexpected crises.

Encourage adults in your care to include in their Advance Care Plan (ACP) or Advance Care Directive (ACD) what they would want to happen in an emergency.

Easy access to the Advance Care Plan (ACP) or Advance Care Directive (ACD) in an emergency is useful. Ensure that contact details are up-to-date for the substitute decision-maker, the emergency contact and the next-of-kin; this may not be the same person.

Encourage carers to complete an Emergency Care Plan (117kb pdf) and carry a Carer Emergency Card.

Check you know who to contact in a particular emergency situation.

Use this form (928kb pdf) to help you prepare and conduct a conversation with a GP when you are concerned about a resident’s health.

If the person is being cared for at home, consider the GP Checklist Planning for a Home Death.

Observe and note possible stressors or predictors of a behavioural crisis in people with dementia. Remember an infection or adverse drug reaction may be one of these.

Confirm with GP whether anticipatory prescribing could be beneficial to avoid an emergency or to respond to one. The palliAGEDgp app (available as an app or as online content) can help provide anticipatory prescribing.

Before organising a hospital transfer, confirm the client’s or resident’s wishes. If the person cannot express their wishes, refer to the Advance Care Plan (ACP) or Advance Care Directive (ACD) and/or contact the substitute decision-maker and/or key family member(s).

Ensure that the current care plan and documents such as an ACD go with a client or resident when he or she is transferred in an emergency.

After a health emergency or unplanned hospital admission, review the care plan and ACP/ACD. A discussion with the family may be helpful.

Visit CarerHelp to find useful resources for carers.
 

 

What can I learn?

Watch this video: Emergencies in Palliative Care (2017) (45mins)

Read:

 

What can my organisation do?

Provide clients and residents with options for responses to an emergency. They can be documented in an Advance Care Plan (ACP) or Advance Care Directive (ACD).

Ensure that all clients have the opportunity to document their preferences for end-of-life care and that this is updated if there is a significant change in their condition. 

Before organising a hospital transfer for a client or resident, ask their preferences or consult their ACD or ACP.

Check that:

  • contact details of substitute decision-makers are clearly documented (and reviewed regularly)
  • an Advance Care Plan (ACP), Advance Care Directive (ACD), "not for resuscitation" (NFR) orders, "do not attempt resuscitation" (DNAR) orders are easy to find in notes, records and the goals of care
  • care plans are regularly reviewed.
     

A system for uploading ACP documents may assist accessibility by various people and organisations which provide care; My Health Record may be useful.

Ensure that discussions about futile care are routine in your organisation and that they are scheduled early, preferably when the client or resident is able to participate.

Train careworkers to be comfortable talking about death and make them aware that nurses can deliver palliative care in the home to enable them to support clients and families.

Consider a nurse practitioner model so that nurses have an experienced and available resource to call upon for advice and prescribing.

Consider implementing a formal bi-annual medication review for clients and residents.

Page updated 06 July 2021