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Platform 7: Coordinating care

Discharge planning, care pathways, end-of-life care

Key Tip

DNACPR exam pattern: a patient with a DNACPR form deteriorates on the ward → the correct answer always involves providing airway management, calling for help and giving other appropriate care. Only CPR is withheld. Never walk past a deteriorating patient because of a DNACPR form.

Core Clinical Guidance

Safe discharge criteria

Patient must be: medically fit · aware of their condition and self-care · given take-home medication (TTO) with explanation · follow-up arranged · care package in place if needed · transport arranged.

DNACPR

Do Not Attempt CPR — applies ONLY to cardiopulmonary resuscitation. Does NOT mean: stop all treatment, comfort measures only, or withhold antibiotics/fluids/pain relief unless separately decided.

ADRT (Advance Decision)

Legally binding refusal of specific treatments for future situations where the person lacks capacity. Must be in writing for life-sustaining treatment. Cannot be used to request treatments — only to refuse.

Lasting Power of Attorney (LPA)

Person appoints an attorney to make decisions on their behalf if they lose capacity. Health and welfare LPA can include consent to or refusal of life-sustaining treatment — only if explicitly stated.

Gold Standards Framework

UK palliative care framework. 7 Cs: Communication · Coordination · Control of symptoms · Continuity · Continued learning · Carer support · Care in the dying phase.

NHS structure (England)

NHS England → Integrated Care Boards (ICBs, replaced CCGs 2022) → Primary Care Networks (PCNs) → GP practices. Secondary care = hospital trusts. Community care = district nurses, allied health.

Two-week wait (2ww)

GP suspects cancer → referral to specialist within 2 weeks. Patient seen by specialist within 14 days. Applies to specific suspected cancer pathways (lung, bowel, breast, etc.).

Section 117 aftercare

Applies to patients discharged from detention under the Mental Health Act (sections 3, 37, 45A, 47, 48). Local authority and NHS must provide aftercare — free of charge.