1. Step 5 workshop

2. Step 5 - Plan Recognising when an individual enters the dying phase Appropriate and inappropriate hospital admissions at end of life Care of relatives, significant others, staff and other residents Religious, cultural and spiritual care

3. Recognising when an individual enters the dying phase The use of a syringe pump at the end of life Recognising and acting on actions to take when an individual is dying What are End of Life Care Plans for the dying patient (or equivalent)

4. Permits appropriate treatment Prevents inappropriate treatment “Missed diagnosis” – leads to conflict within the clinical team – leads to conflict with individuals and relatives

5. Early recognition of dying is vital Allows time to consider reversible causes and appropriateness of action plan. Allows time to talk to all involved (individual, professionals and family) and agree a plan of care (ACP, DNACPR) Prevents crises, inappropriate hospital admissions or treatments Individuals and relatives have opportunity to make fully informed choices about future

6. Profound weakness Bedbound Increasing drowsiness/ semi- comatose Unable to tolerate oral medications Minimal food or fluid intake Disorientated Muscle jerks Gaunt physical appearance Poor colour Poor peripheral perfusion Increased sweating

7. Sudden death may occur in all types of disease Excluding reversible causes is difficult in all forms of disease http://www.bioethics.gov/images/living_well_graph.gif

8. Communication – The individual – The relatives – GP/DN – Out of Hours – Hospice outreach Symptom control (anticipatory prescribing) Withdrawal of futile and inappropriate treatments and investigations End of Life Care Plan

9. Local Individualised End of Life Care Plan for the dying adult Insert local copy

11. Pain Thorough, holistic assessment of pain essential (remember 2/3 people have more than one pain) Regular administration of analgesia Appropriate medication (or combination of) for pain type Dose titration Regular reassessment

12. Terminal Secretions Often cause greater distress to family and staff than individuals Problematic to treat unless caught early Especially prevalent in individuals with: Oedema/ascites Lung cancer Chest infections Respiratory disease Manage with: Repositioning Good mouth care Reassurance to family Medication

13. Breathlessness Management: General comfort measures Calm approach to individual Orthopnoeic positions Use of fans/ air flow Extra “personal space” Relaxation techniques Education of individual and family Oxygen may help, but not for all Medication – treat underlying condition, opiates, benzodiazepines 13

14. Agitation Agitation, within a palliative care definition, is usually associated with the symptoms of restlessness and distress seen at the end of life Reversible causes should always be excluded, e.g., urinary retention or incontinence, constipation, dry mouth/ hunger /thirst, pain, spiritual distress Management may include: Minimise new faces Minimise interventions Address environment (noise/lighting etc) Assess other stimuli (touch/music/smell etc) Medication

15. Break time…

16. What is an appropriate hospital admission at end of life? HOME RISKS- Anything that cannot be done in the home HOSPITAL RISKS- unfamiliar people, unfamiliar place, inappropriate interventions, too busy BENEFITS- familiar place, familiar caring people, relationship with family, personalised care, dignity & peace BENEFITS- medical help at hand Anything that cannot be done in the home

17. Significant Event Analysis (SEA) The importance of reflection

18. Significant Event Analysis What went well? What did not go well? What could have been done better? What would you have done differently?

19. Planning individual care INDIVIDUAL’S NAME: NHS NUMBER: DOB: DATE: CARE PLAN: The person is approaching end of life: Anticipated problemsActual problems - DATEGoalsActions - DATE Pain Nausea Vomiting Respiratory problems Incontinence Bladder problems Constipation Unable to eat & drink Unable to take oral medication Skin/mouth problems Mobility Agitation Confusion Family support needed Psychological support needed Spiritual support needed ADVANCE CARE PLAN DNACPR GP DISTRICT NURSES OOH SERVICE Other

20. What do you do to prevent inappropriate hospital admissions?

21. What can support decision making at the end of life? ACP- has this been revisited? Out of Hours (OOH) handovers across all staff GP Review if appropriate DN support Holistic assessment Communication with acute sector Communicate with other appropriate professionals - SPC team

23. Supporting Staff Extra physical work? Emotional stress Removing the taboo- the traffic lights Its ok to show feelings Supervision- could you use reflection? Peer support

24. Supporting families, friends and significant others How do you tell families, friends and significant others when someone is dying? Are there any particular people who may be more affected than others? Should this be discussed?

25. Spiritual support What different needs can you think about? How are these needs addressed? What might your role be? Religious needs resource www.queenscourt.org.uk/spirit

26. Any questions?