The following information aims to demonstrate, using a fictional case study, how the comprehensive model for personalised care can be applied within a service. This example demonstrates the potential impact in the palliative and end of life care context.

The scenario

Mrs C. is a widow who lives on her own. She has three children and the nearest lives two hours’ drive away. She has long- standing COPD, but over the past year this has become increasingly severe, and she has needed two hospital admissions. Two months ago, she was diagnosed with lung cancer with secondaries to her bone and liver. The following illustrates the opportunities and benefits of personalised care as seen through Mrs C.'s eyes.

To support effective personalised care, in an ideal scenario, Mrs C. would be involved in the coordination of her care and options. Assessment and subsequent planning would be effectively shared so that Mrs C. does not have to repeatedly tell her story and her care would join up to ensure a comprehensive and integrated response. This coordination can be led by any appropriate professional and may be the responsibility of a multidisciplinary team.

Shared decision making

There are many opportunities and critical points for shared decision making for Mrs C., which include:

• • deciding whether to accept palliative treatment for her lung cancer;

• • deciding what level of treatment/ intervention she would wish in the event of another exacerbation of COPD – including hospital admission – discussion about the thresholds for these decisions – for example, severity of breathlessness and availability of carers;

• • deciding whether to record her wishes about future care at this stage, including decisions about cardiopulmonary resuscitation;

• • deciding what sorts of intervention she would prefer for symptom management, knowing their side effects.

Personalised care and support planning

The personalised care and support planning process for Mrs C. can include:

• • holistic assessment of physical, psychological, emotional, social, and spiritual needs;

• • discussion about what matters most to her;

• • discussion about how this will be incorporated into a personalised care and support plan, and discussion about when and how a review is triggered;

• • discussions about the level of personal care she needs now – for example, she decides that she only needs morning carers;