Trim number: (Ambulance use only) | | Document number: (Ambulance use only) |
Patient name: | <PtName> | DOB: | <PtDoB>

NSW Ambulance Adult Palliative Care Plan 

Date of application: | <TodaysDate> | Review date:            (12 mths or less) |

Surname: | <PtSurname> | Date of Birth: | <PtDoB>
Given name/s: | <PtFirstName> | Sex: | <PtSex>

Address:

<PtAddress>

Contact number:

<PtPhoneMob> (M)
<PtPhoneH> (H)

Interpreter required: | <Interpreter required?> | Language: | <PtLanguage Spoken>

CARDIAC ARREST TREATMENT DECISION
If the patient is in cardiac arrest: <IF THE PATIENT IS IN CARDIAC ARREST:>

Please check the statements which are appliable (may be more than one):

| If withholding CPR, the patient, family and/or enduring guardian and I, as treating clinician, have considered the care options and a decision to withhold resuscitation has been made based on the discussion between the patient, family and/or enduring guardian.
| The patient's current medical diagnosis and prognosis is such that if CPR is successful it is likely to be followed by a length and quailty of life which is not in the wishes of the patient.
| Initiation of CPR is not in accordance with the orally expressed and/or documented wishes of the patient who is/was mentally competent at the time of making the decision.
| If initiation of CPR is not in conjunction with an Authorised Care Directive (ACD).
   
NOTE: If concerns arise about the validity of the documents or the safety of the environment, NSW Ambulance protocol will be followed.

TREATMENT AND MEDICATION OPTIONS
In cases where the patient is not in cardiac arrest, the following treatment and medication options have been considered appropriate through consultation with the patient and/or family and/or enduring guardian:
Airway Management: | Administer | Withhold
Oxygen: | Administer | Withhold
Nasopharyngeal suctioning: | Administer | Withhold
IV access: | Administer | Withhold

The following medications are to be administered by NSW Ambulance Paramedics as directed. Please note: medications outside of the NSW Ambulance clinical scope of practice are required to be with the patient at all times. 

Medication | Dose/Route | Repeat times and intervals

CLINICIAN DETAILS
Name: | <DrName> | Contact number: | <DrPhone>
Provider number: | <DrProviderNo> | Fax: | <DrFax>
Practice name: | <Practice> | Practice address: | <DrAddress>
Email: | | |

As the treating clinician, I authorise this Care Plan and by signing this form I authorise NSW Ambulance Paramedics to implement the treatment options specified which have been discussed with the patient and consistent with their treatment requirements. 

Signature: | | Date: | <Date>

PATIENT CLINICAL HISTORY

Diagnosis:

<PMHActive>

History:

<FamilyHx>
<SocialHx>

Co-morbidities:

Current medications:

<CurrentRx>

Allergies:

<Reactions>

FAMILY/ENDURING GUARDIAN
Surname: | <NOKName> | Given name: |
Relationship: | <NOKRelation> | Address: |
Contact number: | <NOKContact> | |
Interpreter required: | | If yes, language: |
All correspondance will be sent to the person identified in this section.

PATIENT/FAMILY/ENDURING GUARDIAN AUTHORISATION
Patient's signature: | | Date: |
Family/Enduring Guardian signature: | | Date: |
LOCATION OF CARE

While every effort will be made to accomodate the patient's wishes, NSW Ambulance will review the location of care at the time of attending the patient, distances and travelling times will be factored into the destination decision.

In the even that care at home becomes too difficult, the choice for end of life care is at:

Should death occur during transport, treatment will be in accordance with the patient's wishes detailed on page 2 of this plan. 

In the event of death during transport the patient should be transported to:

POST DEATH MANAGEMENT PLAN

If the patient dies, the management of the patient is the responsibilty of the clinician/palliative care team. Paramedics should contact the patients: 

General Practitioner name: 
Phone:

OR

Palliative Care Team:
Phone (BH):
Phone (AH):

CONTACT LIST
TEAM | Name | Contact Number (BH) | Contact Number (BH)
General Practitioner | | |
Palliative Care Team | | |
Primary Care Team | | |
Community Nurse | | |
Other Health Services | | |
Spiritual/Religious Support | | |

NSW AMBULANCE USE ONLY
Endorsed by:
Signature: | | Date: |

Please fax completed form to: (02) 9320 7380 or scan/email to: protocolp1@ambulance.nsw.gov.au