NSW Ambulance Authorised Paediatric Palliative Care Plan 

Date of application:		Review date:		
Trim number:		Document number:		

Surname:	<<Patient Demographics:Surname>>	Date of Birth:	<<Patient Demographics:DOB>>	
Given name/s:	<<Patient Demographics:First Name>>	Sex:	<<Patient Demographics:Gender>>	
Address:	<<Patient Demographics:Full Address>>	Contact number:	<<Patient Demographics:Phone (Mobile)>> (M)
<<Patient Demographics:Phone (Home)>> (H)	
Interpreter required:	<<Interpreter required?>>	Language:	<<Patient Demographics:Language Spoken>>	
Weight:				

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:	<<Doctor:Name>>	Contact number:	<<Doctor:Phone>>	
Provider number:	<<Doctor:Provider Number>>	Fax:	<<Doctor:Fax>>	
Practice name:	<<Practice:Name>>	Practice address:	<<Practice:Address>>	
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: 	
<<Miscellaneous:Date>>	

PATIENT CLINICAL HISTORY	

Diagnosis:

<<Clinical Details:History List>>

History:

<<Clinical Details:Family History>>
<<Clinical Details:Social History>>

Co-morbidities:

Current medications:

<<Clinical Details:Medication List>>

Allergies:

<<Clinical Details:Allergies/Adverse Reactions>>

PARENT/FAMILY/ENDURING GUARDIAN 	
Surname:		Given name:		
Relationship:		Address:		
Contact number:				
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	

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

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.

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):
DEPARTMENT OF FAMILY AND COMMUNITY SERVICES	

Is the patient known to the Department of Family and Community Services (formally DOCS):

If yes (please tick):

	Family and Community Services are aware of the patient's condition and treatment decisions	
	In the event of the patient's death Family and Community Services should be notified	

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: