The Welsh Ambulance Services NHS Trust (WAST) are increasingly called to palliative care patients at a point of sudden deterioration or crisis. The responding paramedic will not know the patient or have access to medical records prior to their arrival, therefore any assistance with information gathering on arrival is extremely useful. Unfortunately the majority of Advance Care Plans (ACPs) that may be found on scene do not always give the information that would be useful at the point of 999 response. WAST has therefore begun to produce its own ACPs for patients that are either likely to require 999 call (through being contacted by other agencies) or for patients that are picked up as frequent callers from 999 call records. These tailored ACPs contain information for the responding paramedic that includes: the patients’ medical condition(s), how advanced their condition is and what they would and would not want in the event of deterioration. They also detail specific actions on treatment for likely symptoms, for example if the patient presents with symptom A, consider approach or medication 1, in the event of further deterioration consider approach/medication 2 (for instance to help nausea, or pain or breathlessness).
The patient may have clearly recorded that they would not want hospital admission in certain circumstances, even if their life is at risk. Although only a small amount of these plans have so far been produced, feedback from patients, paramedics and professionals working with the patient has been very promising and unwanted admissions have been avoided as a result. Welsh ambulance paramedics have also received Serious Illness Conversation Cymru training (see Velindre NHS Trust and End of Life Care Board projects) in order to demonstrate that there is more to the work of a paramedic than interventional care and admission to acute sector; paramedics can be key to helping provide reassurance and comfort care, and should be a key part of the wider healthcare team that provides the option for palliative care patients to remain at home, in comfort or link up with hospice services.
How can my fridge help? The Message in a Bottle Scheme for important forms.
It may not be deemed practical for a person to carry a DNACPR or ADRT form at all times but we would encourage this whenever possible, and for family members, friends, neighbours to also be aware of these wishes and perhaps even have a copy of the form available or photograph them with their phone. A few patients have in the past ordered medical alert bracelets, as an additional form of communication: these can be engraved with a message, such as: “I have an Advance Care Plan” or “Please read my Advance Decision to Refuse Treatment form in my purse”. http://www.amazon.co.uk/Medic Alert Bracelets
In a home situation, there is the so-called Green Bottle scheme, with a sticker inside the front door, and it is well established in Wales: paramedics look for a green sticker inside the front door routinely when they go on house calls, which alerts to the presence of a green bottle in the fridge. Then they know there is something important they have to check for. Anyone can put their DNACPR form or ADRT in a green bottle in the fridge, or a written instruction as to where to find all the important forms in the house (“DNACPR is in living room on bottom left shelf”). The Lions website has more information on this. (1) The UK Lions Clubs supply the bottles to health centres, doctors’ surgeries and chemists, but other green bottles can also be used. The green Lions bottles are also available directly from Lions Clubs (0845 833 9502 for details of your local club).
The recording of DNACPR status on the electronic digital individual patient record is currently being pursued and will assist in the confirmation of a person’s CPR decision across agencies when developed. Work is also ongoing to develop an electronic record of advance/future care plans for Wales with electronic access to all healthcare providers (with patient’s consent), including patients.