Focus Topics

topic 1 | Activity 9: The team implements an end-of-life care plan

Betty has been very unwell for a few months and has been unable to attend the CKD clinic at the hospital. She is now bed-bound and extremely weak. Leanne has visited her at home in conjunction with the community palliative care team and Betty’s GP.

The CKD team are meeting following the recent results that Betty’s kidney disease is now end-stage.

Betty is experiencing many of the multisystem effects of uremia, including pruritis, nausea, extreme lethargy and weakness, and anaemia. She is also having trouble swallowing her tablets.

The team suggest a case conference to coordinate a plan of care to manage these multiple issues and to ensure that Betty is able to die at home, as she wants to, supported by her GP and the palliative care team.

  1. Leanne suggests holding a case conference with the GP and the community palliative care team to address Betty’s end-of-life needs. Write an agenda for this case conference – include key priorities and the team member responsible for each.
  2. How might the outcomes of this team meeting be communicated to Betty and her family?
  3. From the perspective of your own profession, what role can you have in Betty’s care now as her illness has progressed to the end-of-life care stage?