The Marie Curie Virtual Advance Care Planning service was set up in response to the vulnerability of care home residents during the COVID-19 crisis. The high degree of variation in completed Coordinate My Care (CMC) records pan-London was identified. Many care home residents and their families had not had discussions about their end-of-life care preferences recorded. As well as providing holistic person-centred information, documenting evidence for the transfer to hospital for those for whom it would be appropriate is vital to enable the health and social care system to provide better person-centred care.
Marie Curie had existing experience of working with care home staff and GPs to create CMC records. This experience was used to initiate and provide this virtual service across several areas in London involving care home residents and the service has expanded to receive referrals from hospital consultants for their out-patients who they believe would benefit from advance care planning and the creation of a CMC record.
The project is staffed with registered nurses, initially with those who were shielding, and Marie Curie were able to recruit these staff from widespread locations because of its virtual nature. A training programme was established involving recognised CMC training, using webinars on advance care planning and issues surrounding mental capacity of patients, including Lasting Power of Attorneys Best Interest Decisions for patients who lack capacity. This was underpinned by the experience of Marie Curie Nurses with excellent communication skills as well as foundational mandatory training such as general data protection, safeguarding and mental capacity assessment.
On receipt of the referral, the Marie Curie Nurse identified individual needs and began liaising with necessary parties in order to create an advance care plan that was of a high quality and would contain the most useful information about personal preferences to the multi-disciplinary teams.
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