For use when:
- There is irreversible deterioration
- Ceilings of treatment/interventions have been reached
- Investigations either no longer appropriate or desired by the patient
- Clinical judgement of multi-disciplinary team (MDT) is that the patient is dying and the Senior Clinician agrees with this.
Significant decisions about a patient’s care including diagnosing dying, are made on the basis of multi-disciplinary discussion
- Regular discussion, review and consideration should be given to decision making and management/treatment plans based on assessment of the needs of the patient/relative/carer/friend.
- Medical interventions/Nursing interventions including the use of the assessment tools – consider discontinuing those that are no longer beneficial to the patient
- Do Not Attempt Cardio Pulmonary Resuscitation (guidance overleaf)
- Regular review of nutrition and hydration needs. Discuss with the patient/relative/carer/friend the benefits or burdens of artificial hydration/nutrition (GMC Good Practice Guidelines / NICE Guideline: Care of Dying Adults in Last Days of Life)
- Medication
- Assess individualised needs of the patient
- Rationalise non essential medications and consider individualised anticipatory prescribing. See guidance overleaf
- Use of continuous subcutaneous infusion if patient is struggling to swallow, or has uncontrolled symptoms not helped by oral or subcutaneous (SC) breakthrough doses
- “Just in case” boxes should be available to patients in the community setting
- Preparing the patient (if appropriate) relative/carer/friend if there is an identified risk of a significant event e.g. catastrophic bleed
Informative, timely and sensitive communication is an essential component of each individual patient’s care
- Regular communication and review of care with the patient/relative/carer/friend and the multi disciplinary team is essential. Ensure any potential communication barriers are identified and addressed e.g. use of interpreters.
- Clearly document any significant conversations (where available use SBAR)
- Identify what is now important to the patient/relative/carer/friend? Does the patient have My Thinking Ahead and Making Plans tool or a Key information Summary (eKIS)
- An Anticipatory Care Plan?
- An Advanced Directive/Living Will?
- Has the patient’s capacity been assessed? If the patient does not have capacity, Section 47 AWI certificate and treatment plan should be completed.
- Does the patient have Welfare Power of Attorney/ Guardianship in place? Has the Guardian/ Attorney been identified and included in discussions? Do we have a copy?
- Discuss preferred place of death. To facilitate transfer see the ‘Rapid Discharge Guidance for Patients who are in the Last Days of Life’.
- Preparing the patient/relative/carer/friend that they are dying - what can happen (‘What Can Happen When Someone is Dying’)
Each individual patient’s physical, psychological, social and spiritual needs are addressed as far as is possible
- Ask questions, listen and respond to worries and fears
- Regular assessment of the patient’s physical symptoms, including bowel and bladder function, as these are treatable causes of distress at end of life
- Continuous review of nutrition and hydration plan. Regular mouth care and oral fluids as able.
- Where possible identify spiritual, religious and cultural needs both before and after death
- Offer to contact Chaplaincy service or their preferred faith/community leader.
Consideration is given to the well-being of relatives or carers attending the patient
- Keep relative/carer/friend updated particularly when there is a change in the patient’s condition or management/treatment plan
- Ask questions, listen and respond to worries and fears
- Flexible visiting appropriate to care setting
- Provision of information appropriate to care setting
DNACPR
DNACPR Considerations for the dying patient
An objective of DNACPR policy is to encourage and facilitate open, appropriate and realistic discussions with patient/relative/carer/friend in the context of agreed goals of care. All discussions and subsequent decisions must be clearly documented.
The dying patient/relative/carer/friend -
- Should be made aware that the DNACPR decision is a clinical one because CPR is contraindicated
- Should not be burdened with feeling that they are responsible for DNACPR decision
- Should be made aware that all appropriate care and supportive treatment will continue
- If further guidance is required please refer to the DNACPR policy
SYMPTOM MANAGEMENT
- Comprehensive symptom management guidance including medication dosing advice can be accessed at Care in last Days of Life
- For patients with stage 4 or 5 acute or chronic kidney disease (eGFR <30ml/min), refer to the guideline Renal Disease in the Last Days of Life
- If a patient has a symptom(s) present, then a SC bolus dose of an appropriate medicine(s) should be administered as soon as possible. If unsure please seek advice from either palliative care or pharmacy.
- If a patient requires 3 or more SC breakthrough doses in 24 hours of any medicines, then consider the use of a continuous subcutaneous infusion (CSCI).
- Anticipatory SC medicines should always be tailored to individual need and prescribed as suggested (Table 1).
- If patient reaching maximum dose of as required medication or symptoms uncontrolled please seek advice from either palliative care or pharmacy.
ANTICIPATORY SUB CUTANEOUS MEDICATIONS INITIAL DOSE SUGGESTIONS
Pain
If patient is receiving oral morphine or a step 2 analgesic (including co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of morphine / diamorphine should be available (1/6th to 1/10th of 24 hour equivalent dose). If opioid naive, consider morphine/diamorphine 2mg SC hourly as required (max 6 doses in 24 hours)
Nausea & vomiting
If patient is receiving an oral anti-emetic and this is effective, then that drug should be available for SC use. See Scottish Palliative Care guidelines under Nausea & Vomiting for medication dosing advice. If the patient is not on an anti-emetic, consider levomepromazine 2.5mg (TWO point FIVE) SC EIGHT hourly as required.
Agitation / restlessness
Prescribe midazolam 2mg SC hourly as required (max 6 doses in 24 hours). Midazolam 10mg/2ml ampoules should be supplied as other strengths are not used in palliative care.
Breathlessness (dyspnoea)
If patient is receiving oral morphine or a step 2 analgesic (including co-codamol 30/500 or equivalent) an appropriate SC breakthrough dose of morphine / diamorphine should be available (1/6th to 1/10th of 24 hour equivalent dose). If opioid naive, consider morphine/diamorphine 2mg SC hourly as required (max 6 doses in 24 hours)
If patient is breathless and anxious, consider the use of sublingual lorazepam 500micrograms 4-6 hourly or midazolam 2mg SC hourly as required (max 6 doses in 24 hours)
Respiratory secretions
Prescribe hyoscine butylbromide 20mg SC hourly as required (max 6 doses in 24 hours)
Further medication advice available from GGC Therapeutics handbook
SUPPORT AND CARE AFTER DEATH
- Support relative/carer/family. Pointers for Staff can be found on ‘Bereavement Card’.
- Bereavement booklet must be offered to relative/carer/friend - Information and Support for Relatives and Friends When Someone Has Died
- Adhere to Last Offices Protocol
- Prepare patient’s property for collection adhering to hospital/care home/hospice policy
- Inform family of need for removal of Implantable Cardiac Devices (ICD) or Pacemaker prior to cremation
- Adhere to the Verification Death policy and complete/ Medical Certificate of Cause of Death (MCCD). Arrange time and date for collection of MCCD form
- Confirm if Procurator Fiscal to be contacted, ensure this is discussed with relative/carer/family, if appropriate/possible in advance of the death.
- Inform relevant HCP of patient’s death e.g. GP, DN, Consultant, CNS
*All resources referenced in this document can be accessed at: www.palliativecareggc.org.uk/professional/eolc/
Created January 2017 by NHSGGC Palliative Care MCN Short Life Working Group. Review date: January 2019 Approved by Medicine Utilisation Sub Group January 2017.
End of Life Care
https://www.palliativecareggc.org.uk/?page_id=66
Download:
https://drive.google.com/file/d/11NhFSe3X00LoIgLBXVqUIfBv8cnuLjFj/view?usp=sharing
https://www.slideshare.net/papahku123/guidance-at-end-of-life-gael-for-health-care-professionals
https://www.scribd.com/document/448335802/Guidance-at-End-of-Life-GAEL-for-Health-Care-Professionals
Palliative and End of Life Care Toolkit
https://sites.google.com/view/pc-eolcare-toolkit/home
Source:
https://www.palliativecareggc.org.uk/wp-content/uploads/2015/08/Guidance-At-End-of-Life-Care-for-Health-Care-Professionals.pdf
