Palliative Pathway Activation

"A plan for living well until dying"

Provider details

Please contact your local POI team for a brief preliminary conversation before completing the PPA.
https://www.poiproject.co.nz/page/contact/


 Date of identifying that the patient needs Palliative Pathway Activation:

Lead provider information

Name of Lead Clinician:
Name of RN/GP Completing Plan:
Local Hospice:
Lead Clinician email: Lead Clinician phone contact(s):
Accounts email:

Patient details:

Patient First Name: Patient Last Name:
Patient NHI:
Patient Date of Birth: Street Address:
Suburb:
Ethnicity: No ethnicity selected...
Best contact for patient: Patient email:

Diagnosis

More information about Supportive and Palliative Care Indicators Tool (SPICT) can be found here


Clinical indication within condition:

Other relevant medical conditions:

List of medications:

Allergies:

Clinical Markers

Describe current functional status

Current Phase of Illness:
AKPS Score:
You can find out more about Phase Assessments here

STABLE:
Patient's problems/symptoms adequately controlled by established plan of care and further interventions to maintain symptom control and quality of life planned and family/carer situation is relatively stable and no new issues apparent

UNSTABLE:
Urgent change in plan of care or emergency treatment required because the patient experiences new problem that was not anticipated in existing plan and/or patient experiences a rapid increase in severity of a current problem and/or family/carer circumstances change suddenly, impacting on patient care

DETERIORATING:
The care plan is addressing anticipated needs, but requires periodic review, because the patient's overall functional status is declining and the patient's experiences a gradual worsening of existing problem(s) and/or the patient experiences a new, but anticipated, problem and/or the family/carer experience gradual worsening distress that impacts on the patient care.

You can view information on how to assess AKPS here


My Care plan

My goals:


Care required to achieve my goals:

My living situation and cultural needs



Requirements to achieve needs:

Next of kin

Name and contact details for main contact person to direct communication: (if different from NOK)

EPOA


EPOA details:

Potential referrals to achieve optimal living situation

My emotional and spiritual needs:
Requirements to achieve needs:

Potential actions to achieve optimal living situation


Additional Support:

Specific support required from Proactive Advisory Service:

Attach Document:



Title:

Patient Statement:


1. PREVIEW ANSWERS 2. PRINT COPY FOR CLINICIAN The plan can be printed, using the button below. 3. SUBMIT (COPY FOR PATIENT) Once you have submitted the plan, a printable version of only the information relevant to the patient will pop up. Please print this for the patient A PDF version of the nal document containing all the fields will be sent securely via email to the Lead Clinician once you submit the completed version

2020 Procon Limited