“The last days”

Cookridge Hospital SHO Teaching

22 February 2005

Best practice in the last hours and days of life

( NICE 2004 Palliative and Supportive care)

Current medications are assessed and non-essentials discontinued

“As required” subcutaneous medication is prescribed according to an agreed protocol to manage pain, agitation, nausea and vomiting and respiratory tract secretions

Decisions are taken to discontinue inappropriate interventions, including blood tests, intravenous fluids and observation of vital signs

Best practice in the last hours and days of life

( NICE 2004 Palliative and Supportive care)

The ability of the patient, family and carers to communicate is assessed

The insights of the patient, family and carers into the patients condition are identified

Religious and spiritual needs of the patient, family and carers are assessed

Best practice in the last hours and days of life

( NICE 2004 Palliative and Supportive care)

Means of informing family and carers of the patients impending death are identified

The family and carers are given appropriate written information

The GP is made aware of the patient’s condition

A plan of care is explained and discussed with the patient, family and carers

Symptom Control

What issues should we think about when trying to manage symptoms at the end of life?

Symptom Control

difficulties

prescribing (or not)

routes of drug administration

pain

terminal agitation

nausea & vomiting

secretions

Withdrawing & withholding treatment

investigations

food

fluids

NG tubes / IV lines

medications

communication

ethical considerations

To stop … or not to stop?

antibiotics

analgesics

PPIs

steroids

antihypertensives

statins

aspirin

antidepressants

anticancer treatment

laxatives

Breaking bad news

be prepared

tact and sensitivity

honest and direct approach

privacy / interruptions

avoid euphemisms

avoid information overload

need for clear understandable information

need to introduce a sense of order

checkout their thoughts and feelings

Caring for the family When a patient’s competence is compromised, relatives can

demand more information. Should relatives have any rights?

70% of complaints to the Ombudsman are brought byrelatives and relate to end of life decisions.

This highlights the need for improved communication.

Can breaking bad news make relatives into secondarypatients?

The patient’s symptoms and treatments can be a cause of great anxiety for relatives and loved ones

The effects on staff

Practical issues

environment

visitors

relatives staying

food & fluids; toilets & showers

after death

Key recommendation of the 2004 NICE guidelines for supportive and palliative

care

Provider organisations should ensure that managed systems to ensure best practice in the care of dying patients are implemented by all MDTs. This might be achieved through the implementation of the Liverpool care pathway for the dying patient.

The Liverpool care pathway

multi-professional document which provides an evidence-based framework for end of life care

developed to transfer the hospice model of care into other settings

replaces all other documentation

The pathway addresses: Comfort measures

Anticipatory prescribing Discontinuation of inappropriate interventions

Psychological care

Spiritual care

Family support

Admission onto the pathway

for entry onto the pathway there has to be consensus amongst members of the MDT that the patient is dying

the patient can come off the pathway in response to improvements in their condition

Diagnosing dying in cancer patients

the patient is bed bound

the patient is semi-comatose

the patient is unable to take sips of fluid

the patient is no longer able to take oral drugs

Components of the LCP

Initial assessment and care of the dying patient

Ongoing care of the dying patient

Care of the family and carers after the death of the patient

Benefits facilitates communication

measurable improvements in the quality of end of life care

addresses inequality re location of terminal care

measurable improvements in documentation

empowering

informs and influences education

informs standard setting and benchmarking

References Ellershaw JE, Smith C, Overill S, Walker SE, Aldridge J (2001) Care of the

dying: Setting standards for symptom control in the last 48 hours of life. Journal of Pain and Symptom Management. 21(1): 12-17

Ellershaw JE (2002) Clinical pathways for care of the dying - an innovation to disseminate clinical excellence. Journal of Palliative Medicine. 5(4): 617-623

Ellershaw JE, Ward C (2003) Care of the dying patient: the last hours or days of life. BMJ, 326: 30-34

Ellershaw JE , Wilkinson S (2003) Care of the Dying: A Pathway to Excellence. Oxford: Oxford University Press

Jack B, Gambles M, Murphy D, Ellershaw JE (2003) Nurses' perceptions of the Liverpool Care Pathway for the Dying Patient in the acute hospital setting. International Journal of Palliative Nursing, 9 (9):375-381

DOH. Essence of Care: Patient-focused benchmarking for health care practitioners. http://www.doh.gov.uk/essenceofcare/ 25/2/2003