People whose health is already poor or deteriorating are at risk of acute health crises and/or dying from underlying conditions.
They may have a serious illness (eg cancer, organ failure or neurological conditions), multiple health conditions, dementia or general frailty in older age, or chronic infections such as TB or HIV. Many are at increased risk during COVID-19.
Prioritise these people for care planning and/or palliative care.
We can use the SPICT indicators for general and advanced health conditions to help us identify them:
*SPICT 2019: in many languages including English, French, German, Italian, Spanish, Portuguese, Dutch, Danish and Swedish.
*SPICT-LIS: is for lower and middle income countries/settings.
*SPICT-4ALL: in lay language is for care workers, patients and families to encourage them to ask for extra help and support.
Some professionals and teams caring for older people also use a frailty tool (e.g. Clinical Frailty Scale, Electronic Frailty Index) or a performance status tool/score to help them identify people whose overall health is declining.
Making prognostic judgements for individuals based on population life-expectancy data is inaccurate. Looking at burden of health-related suffering and/or for signs of unstable/declining health (e.g. Palliative Care Phase tool) are more valid and appropriate.
Care Planning Steps
People at risk of deteriorating and dying from current health problems, complication, or other illnesses including coronavirus.
– usual health status, severity of underlying conditions/general frailty, decision-making capacity/healthcare proxy
– current treatment & care plans (including any advance (anticipatory) care plan or resuscitation status form)
– likely clinical outcomes of possible interventions (eg cardiopulmonary resuscitation, oxygen, hospital care/ITU referral)
Talk – about what is happening, what is important, and what we can do to help.
Involve the person and those close to them.
Find out how this person would like to be cared for. Is there treatment/care they do not want?
Actions to plan
-Place of care if person is more unwell or likely to be dying
-Specific plans for sudden illness, complications, infection (including COVID-19); end-of-life care plan if dying.
-Talk about cardiopulmonary resuscitation (CPR) outcomes if it would not work or leave the person in much poorer health.
-Review medications; plan for anticipatory/ emergency medicines, if appropriate.
-Holistic care (physical, psychological, family, practical, spiritual)
– Offer to speak on the phone with family/a close friend, if appropriate.
Record plans – share with professionals and teams who need access to this information; keep plans updated
Ask – for help if you need it. Look out for other staff you can support or help too.
Talking about planning care, death and dying
It has always been important for us to talk with people whose health is deteriorating gradually or more rapidly due to underlying health problems about care planning and what matters to them, and to involve families. During the COVID-19 epidemic, we need to communicate using clear, sensitive and effective language while also doing our best to adapt to PPE and visiting limitations.
RED-MAP: Guide for Advance (Anticipatory) Care Planning (ACP) conversations. RED-MAP Poster (May 2020)
DECIDE: Guide for shared decision-making discussions about treatment/ care options. (DECIDE card – 2020)
[developed with NHS Education for Scotland].
EC4H tutors’ presentation (video) – Having realistic conversations: shared decision-making in practice (2019)
Good Life, Good Death, Good Grief (Public information on death and bereavement).
RED-MAP is a 6-step approach to conversations about planning care, deteriorating health and dying developed in Scotland and with SPICT partners in the UK and internationally. It is suitable for all care settings.
R eady: Can we talk about your health and care and what the coronavirus situation might mean for you?
E xpect: What do you know? What do you think might happen? Do you have any questions or worries?
D iagnosis: What we know is…. What we don’t know is… What we are not sure about is…
M atters: What’s important to you (and your family) if you were to get unwell/very ill?
How would you like to be cared for? Is there anything you don’t want?
A ctions: What we can do to help is….Options we have are…. This does not work or help when/if/because…..
P lan: We can make a plan for treatment and care for you, and your family.
– Each step in RED-MAP is important, as is the order of the steps.
– Suggested phrases are adapted to the person or family, place of care and context of the discussion.
– Always refer to the person by name when talking with their family or a close friend.
– If talking with people by phone: check you have the right person; ask if it is a good time; speak slowly in shorter sentences; check what’s been understood and how people are.
– Ask for help and support from colleagues, senior staff or a specialist. Seek a second opinion, if needed.
RED-MAP is part of the Building on the Best programme in Scotland.
[Funded by Macmillan Cancer Support.]
RED-MAP Guide for Professionals (updated 8/6/20)
RED-MAP Guide to talking with care home residents about care planning (19/5/20)
RED-MAP Guide to talking with family/friends of care home residents about care planning (19/5/20)
Advance (Anticipatory) Care Planning in Care Homes – Key steps for clinical staff (3/6/20)
Talking with people by phone (general tips & advice – poster 28/4/20)
Telling relatives by phone about death of a patient from COVID-19. (Oxford University)
Healthcare Improvement Scotland (ihub) (ACP for COVID-19)
Avoid words and phrases that can make people feel confused, abandoned or deprived of treatment and care.
There is ‘nothing more’ we can do. ‘Ceiling’ of treatment or care for a person.
We are ‘withdrawing’ treatment. Treatment is ‘futile’. ‘Would you like to be resuscitated?’
NHS Education for Scotland (NES) module – Shared decision-making, 2019 (opens in new window)
ANZICS (Australia and New Zealand Intensive Care Society) Guidance: Communication in critical illness.
(Open in new window)
Effective Communication for Healthcare (EC4H) Clinical communication in practice and education – resources for professionals.
European Association for Palliative Care (EAPC) – COVID resources
End of Life Directions for Aged Care (ELDAC) (Australia)
VitalTalk: Communication resources for COVID (USA)
The Conversation Project (USA)
Real Talk UK (evidence-based clinical communication guidance)