Case conferences between general practitioners and specialist teams to plan end of life care of people with end stage heart failure and lung disease: an exploratory pilot study

Table 1 The PEPSI COLA structure of palliative care health plans[9]

Domain	Issues to consider	Domain	Issues to consider
Physical	Symptom control	Control	Choice, dignity
	Medication – regular and as needed		Treatment options/Management Plan
	Compliance/stopping non-essentials		Advance directive
	Complementary therapies		Place of death
Emotional	Understanding expectations	Out of hours/emergency	Continuity
	Depression and adjustment		Provision of out of hours care to patients/carers
	Fears/Security		Provision of out of hours care to patients/carers
	Relationships		Carer support
			Medical support
			Drugs and equipment
Personal	Spiritual/religious needs	Late	End of life/Terminal care
	Inner journey		Stopped non-urgent treatment
	Quality of life		Patient and family aware
	Patient/carer agenda		Comfort measures/Spiritual care
	Patient/carer agenda		Rattle, agitation
Social Support	Benefits/Financial	Afterwards	Bereavement follow-up/others informed
	Care for carers		Bereavement follow-up/others informed
	Practical support		Family support
			Assessment/Audit
			Support team
Information/communication	Within Team
	Between professionals
	To and from patient
	To and from carers

ISSN: 1472-684X