End of Life Care Planning Rita Gallagher Newpark Care Centre

End of Life Care planning The end of life of phase ‘applies to people with a variety conditions and involves a longer time period than the days or weeks immediately before death.( NCAOP 2008)

End of life care planning ‘care that helps all those with advanced, progressive, incurable illness to live as well as possible until they die’ e.g. those with Dementia, Recurrent repeat infections, exacerbation of chronic illness The NHS (2007)defines EOLC as

End of life care planning This enables supportive, palliative care needs of both the resident and their family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms plus the provision of psychological, social and practical support

End of life care planning Physician Orders for Life-Sustaining Treatment POLST

End of life care planning Nursing Homes Nursing Projects In association with Dr S. Kennelly -Inappropriate presentations at A&E -EOLC Trial of Regina Mc Quillan, initial work on EOLC and POLST type document, we adapted it slightly before we adopted it.

Section D Check One Box Only in Each Column MEDICALLY ADMINSTERED FLUIDS AND NUTRITION: Oral fluids and nutrition must be offered if medically feasible.  No iv fluids  No feeding tube  S/c fluids for a defined trial period  feeding tube for a defined trial period  s/c fluids long- term if indicated  Feeding tube long- term Other instructions (e.g. alternative hand-feeding care plan in place if appropriate):_________________________ __________________________________________________________________________________________ Section E ANTICIPATORY PRESCRIBING: Please be aware of special circumstances which might require different drugs- use clinical judgement Oral medications 1)Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort & pyrexia 1)Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea 1)Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea Subcutaneous medications ( where patients no longer able to take oral medications ) 1)Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea 1)Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness 1)Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions. **Medications to be prescribed at discretion of general practitioner. Consider Diclofenac 100mg pr where no contraindications to same Medications  Medications rationalised where possible to reduce tablet burden and where no longer appropriate given patient’s condition and prognosis. Section F Nursing and Support services ( to be organised by hospital medical + nursing team where patient is being discharged from hospital or if patient being transferred from nursing home to hospital)  Liaise with hospital palliative care team  Liaise with community intervention team as appropriate  Date of discharge confirmed with Patient/family and nursing home  Confirmation that medications available in nursing home 24 hours prior to transfer  Appropriate transport arranged and confirmed, DNR letter for ambulance crew  Fully comprehensive nursing discharge letter Section G Specialist Palliative Care Input To be completed by specialist palliative care only  Patient seen in Hospital  Patient for Community Palliative Care from Location __________________________________________  Patient not for Community Palliative care; Medical Officer can contact appropriate Community Palliative Care service for advice Date: ___________________________ Review Date (3 months) ____________ Signature: _____________________________________ (GP/ Consultant) Signature: ________________________________ (Director Of Nursing) Name: _______________________________ Address: _____________________________ Date of Birth: ________________________ M.R.N Number: ______________________ (if in hospital) These are guidelines for the medical/ nursing team based on the patient ’ s medical condition and wishes. A COPY SHOULD BE KEPT IN THE PATIENT ’ S MEDICAL RECORDS IN THE HOSPITAL AND IN THE NURSING HOME andshould accompany patient when transferred. This document should be discussed with patient/family, nursing home manager and GP prior to transfer if patient is being discharged from hospital. THIS IS NOT A TICK BOX EXERCISE NEWPARK CARE CENTRE / GUIDELINES FOR PATIENTS RESIDENT IN /RETURNING TO NURSING HOME FOR SUPPORTIVE-COMFORT CARE Name of GP/ Medical Officer with whom this plan discussed Name of Director of Nursing / Clinical Nurse Manager with whom this plan discussed Name/s of family members with whom this plan discussed The basis for these orders is:  Patient’s preferences  Patient’s best interest Section A Check One Box Only CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse andis not breathing.  Attempt Resuscitate (CPR)  Do Not Attempt Resuscitation (no CPR) If DNR, letter for ambulance crew When not in cardiopulmonary arrest, follow B, C and D Section B Check One Box Only MEDICAL INTERVENTIONS:  Comfort measures Treat with dignity and respect Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Refer to Section C re antibiotic care plan. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Refer to Section D for nutrition and fluid plan. Do not transfer to hospital for life–sustaining treatment. Transfer only if comfort needs cannot be met in current location.  Limited Additional Interventions Includes care described above. Use medical treatment. Refer to Section C re antibiotic care plan. Refer to Section D for nutrition and fluid plan. Do not use intubation, advanced airway interventions, or mechanical ventilation. Transfer to hospitalif indicated. Avoid intensive care  Full Treatment Includes care above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer to hospital is indicated. Include intensive care. Other instructions:_______________________________________________

End of life care planning discussions in that regard can be complex, lengthy and make take more than 1 conversation ! Guidelines for use: ALWAYS try to ascertain the views of resident Decisions re personal health rest primarily with the resident AND medical team ONLY Family collaboration is important GP involvement essential COMMUNICATION IS KEY

Important that these discussion around EOLC are made at senior staff level- Residents MUST be made aware that there are occasions where transfer to hospital would be in their best interests e.g fracture The EOLC document is photocopied and travels with the resident Anticipatory medications are written up by GP Document Review usually 3/12

And you might think its all over/Done Be prepared! you may have to revisit WHY ? LISTENING TO RESIDENT- RATIONALE FOR DISCUSSION APPROPRIATE TREATMENTS COMPLEX CONVERSATIONS CLEAR COMMUNICATION BETWEEN EVERYONE INVOLVED SUPPORT

End of life care planning This document is not stand alone and MUST be used in conjunction with care planning. Care plans should include details of residents wishes on EOLC Wishes and expectations if they become unwell Views on transfers to hospital All staff must be aware of their wishes Family must be aware COMMNICATION IS KEY Good robust documentation is important

End of life care planning In 2012 there were 17 deaths in my facility 15 had EOLC plans in place Those 15 were cared for in the nursing home and passed away there 1 was a respite who became unwell and died in nursing home 1 suffered a trauma and was transferred to hospital where they passed away This process takes a lot of time, good rapport with GP, knowledge of the resident and their condition, getting to know resident and family,family dynamics and being confident in the care your facility can deliver.

End of life care planning Of interest perhaps adapted from Australian aged care (Queensland Government) Adapted from Residential Aged Care end of Life Care Pathway Comfort care plan docs-Instructions for completing Pathway Very useful for monitoring care when a resident is very ill They assist with decision making process Ensure there is a clear rationale for administering medication (anticipatory) Is excellent at tracking care for nurses -at change of shifts- for other allied health care staff –gp, and the likes of me DON

Comfort Care Document

End of life care planning Thank you Any Questions ?