Advance planning
GPs and primary health care teams can support people with dementia, and their carers/families, by:
- discussing people’s wishes, preferences and plans as the end of life approaches; having open and honest communication, and being alert to triggers and opportunities for these difficult discussions; agreeing an advance care plan where appropriate and possible;
- agreeing with the patient and carers/families their care plan, regularly reviewing with them their needs and preferences as their needs and circumstances change; taking into account and making reasonable adjustments for people’s capacity to make decisions;
Timely support and services
ensuring that all people with dementia – at home, and in care homes – and their carers/families have access to end of life care services, including access to:
- expert prescribing,
- palliative and pain control services
- expert dementia care including Admiral Nurses, community nurses, palliative care teams, dementia advisors, peer support and volunteers.
Anticipating needs; planning and co-ordinating care
Ensuring that care is co-ordinated and communicated with the primary health care team, and that people with dementia are on the Practice’s end of life care register. Anticipatory care planning may include:
- managing physical symptoms and changes in behaviour;
- managing complications such as pneumonia, febrile episodes and swallowing and eating problems;
- avoiding admission to hospital; and/or facilitating early discharge if admitted to hospital;
Supporting people at home, and in care homes
- arranging for equipment to be provided to enable people to remain at home, or in their care home;
- ensuring people have access to high quality out-of-hours support;
- ensuring that carers and families are signposted to advice and support for palliative care;
- signposting people to sources of emotional and spiritual support, as appropriate.
Toward the end of life, and after death
Recognising when the person with dementia is reaching the end of life;
- putting in place care as agreed, to maintain their comfort and dignity;
- ensuring that carers/families are supported;
- supporting carers/families when they are bereaved, ensuring that they have ongoing practical and emotional support.
Useful resources