ADRT completed Yes No (Advance Decision to Refuse □ □ Treatment) Yes No DNAR-CPR completed □ □ (Do Not Attempt Resuscitation) Yes No Best Interest Discussion took place □ □ Yes No Out of Hours Teams informed of □ □ individual’s status Yes No Specialist Palliative Service involved □ □ (e.g. Macmillan, Hospice) Yes No Anticipatory drugs in place □ □ Service user supported by an Yes No Died in hospital individual plan of care for the dying □ □ □ person (or equivalent) If so, how many days was the service user supported by the individual plan of care for the dying person? Number of unplanned admissions that occurred in last year Reason for each unplanned admission Yes No DS1500 benefit application initiated □ □ Cause of death Home Hospital Hospice Ambulance Place of death □ □ □ □ If the individual died in hospital which hospital? Date of admission Yes No Out of Hours admission □ □ Reasons for admission Date of Death Yes No Bereavement Support offered to □ □ family/friends Yes No Bereavement Support offered to other □ □ individuals Yes No Bereavement Support offered to staff □ □
ADRT completed (Advance Decision to Refuse Treatment) Yes □ No □ DNAR-CPR completed (Do Not Attempt Resuscitation) Yes □ No □ Best Interest Discussion took place Yes □ No □ Out of Hours Teams informed of individual’s status Yes □ No □ Specialist Palliative Service involved (e.g. Macmillan, Hospice) Yes □ No □ Anticipatory drugs in place Yes □ No □ Service user supported by an individual plan of care for the dying person (or equivalent) Yes □ No □ Died in hospital □ If so, how many days was the service user supported by the individual plan of care for the dying person? Number of unplanned admissions that occurred in last year Reason for each unplanned admission DS1500 benefit application initiated Yes □ No □ Cause of death Place of death Home □ Hospital □ Hospice □ Ambulance □ If the individual died in hospital which hospital? Date of admission Out of Hours admission Yes □ No □ Reasons for admission Date of Death Bereavement Support offered to family/friends Yes □ No □ Bereavement Support offered to other individuals Yes □ No □ Bereavement Support offered to staff Yes □ No □
Six_Steps_3._DCO_PDI_Interim.docx