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Personalised Care Support Planning (PCSP) Toolkit

Identification of the last 12 months can be incredibly challenging for clinicians, particularly in the frail elderly. Proactive care and support planning is essential to enabling a patient’s wishes for care at the end of life to be supported and to prevent crisis. The aim is to support the patient to live as well as possible for the time they have remaining.  

Late recognition of the end of life can impact on both the choice of place of care and patient-centred decisions, which can both lead to inappropriate life-saving interventions and to under-treatment of palliative symptoms and concerns.   

It should be accepted that in any prognosis there will be some degree of uncertainty and the focus should move from identifying dying to a focus on planning, where there are several possible outcomes for the immediate presenting problem, but the patient’s overall journey is moving towards the end of life.     

Once this trajectory has been identified, then the patient’s wishes can be understood, clinical possibilities can be planned for in a personalised, shared decision making way between patients, their loved ones and clinicians.  

Communicating these wishes to all professionals involved in a person’s care through an advance care plan can support these wishes to be achieved.  Escalation of care is often initiated when those caring for an individual do not know their wishes. Instead of the familiar home environment, those in their final weeks, days or hours are often cared for in clinically inappropriate environments surrounded by the noise of a busy hospital ward.  

Identification of an end of life journey, is often made through situational diagnosis, combining clinical factors which indicate an end of life need.  

The below parameters may be used by health and social care professionals to guide a multi-disciplinary team discussion regarding a patient’s prognosis:  

  • Two or more unplanned hospital admissions in the past 6-12 months  
  • Persistent and recurrent infections  
  • Weight loss of 5-10% in the past 6 months  
  • Multiple morbidity in addition to frailty  
  • Combined frailty and dementia  
  • Delirium  
  • Exacerbation of falling  
  • Rapidly rising frailty score  
  • Escalating patient, family or service provider distress  
  • Request for palliative care support and/or withdrawal of active treatment  

It should be remembered that it is the risk of deterioration which should, across all care settings, be a trigger for end of life care planning, not deterioration itself. The objective of pro-active advance care planning is to support patients to live as well as possible, taking into account the wishes of the patients and their loved ones.  

Advance care planning quick guide 

My future wishes - advance care planning for people with dementia in all care settings