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Learning modules

Activity 9: The team implements an end-of-life care plan

Betty has been very unwell for a few months and has been unable to attend the CKD clinic at the hospital. She is now bed-bound and extremely weak. Leanne has visited her at home in conjunction with the community palliative care team and Betty’s GP.

The CKD team are meeting following the recent results that Betty’s kidney disease is now end stage.

Betty is experiencing many of the multisystem effects of uremia, including pruritis, nausea, extreme lethargy and weakness, and anaemia. She is also having trouble swallowing her tablets.

The team suggest a case conference to coordinate a plan of care to manage these multiple issues and to ensure that Betty is able to die at home, as she wants to, supported by her GP and the palliative care team.

The team implements an end-of-life care plan

Thinking points