“The last days” Cookridge Hospital SHO Teaching 22 February 2005

Your experiences  What experiences have you had?  What’s been good?  What’s been bad?  What do you think is important at the end of life?

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) 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) 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

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

Communication

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 by relatives and relate to end of life decisions.  This highlights the need for improved communication.  Can breaking bad news make relatives into secondary patients?  The patient’s symptoms and treatments can be a cause of great anxiety for relatives and loved ones  The effects on staff

Practical Issues

Practical issues  environment  visitors  relatives staying  food & fluids; toilets & showers  after death

Pathway for the Care of the Dying

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):  Ellershaw JE (2002) Clinical pathways for care of the dying - an innovation to disseminate clinical excellence. Journal of Palliative Medicine. 5(4):  Ellershaw JE, Ward C (2003) Care of the dying patient: the last hours or days of life. BMJ, 326:  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):  DOH. Essence of Care: Patient-focused benchmarking for health care practitioners. 25/2/2003