Abstract

Specialist palliative care units are evolving. The ability to be more reactive in managing medical crises has enabled hospices to treat conditions such as pneumonia with intravenous antibiotics rather than transferring them to an acute trust.

With this greater ability comes greater responsibility. For these decisions to be made correctly and in conjunction with the patient and family, there is a need for highly coordinated and effective multidisciplinary team working.

With hospices becoming more involved with training of doctors, this brings huge benefits and also challenges to the units. Trainees in palliative medicine are at varying levels of training, and work closely with clinical assistants and specialty doctors.

This rich tapestry of the medical team means we need to have safe and effective handovers and medical decision making processes that are transparent and communicated properly.

Therefore, in an easy to remember format, I have devised the D.R.E.A.M. to act as a prompt for important palliative care issues that need to be considered.

It is a way of prompting both the clinician, and the multi-disciplinary team to consider the best care of the patient in a structured way.

The DREAM is completed on admission, and twice weekly within the wider MDT ward rounds.

D Discharge planning and Discussions

Careful and sensitive Discussions, Documented, Discharge planning.

R Resuscitation Status

Ensure this is considered on admission, unified/Hospice DNACPR documented.

E Escalation of Care Decisions

Decisions on level of treatment planned e.g. IV antibiotics, transfer out.

A Anti-coagulation/Advance Care Planning (ACP)

Prompt for medical decision making process. Evidence to support use of prophylactic heparin exists in the Palliative arena. Prompt to record and share ACP discussions.

M Mental Capacity Act (MCA)

Prompt to consider Capacity and all aspects of the Act, including DOLS, LPA and ADRTs.