Transcript 6 STEPS to Success in End of Life Care for residential homes

Step 5 workshop
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
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)
• Permits appropriate treatment
• Prevents inappropriate treatment
• “Missed diagnosis”
– leads to conflict within the clinical team
– leads to conflict with individuals and relatives
• 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
• Profound weakness
• Bedbound
• Increasing
drowsiness/ semicomatose
• Unable to tolerate
oral medications
• Minimal food or
fluid intake
• Disorientated
• Muscle jerks
• Gaunt physical
appearance
• Poor colour
• Poor peripheral
perfusion
• Increased sweating
• 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
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Communication
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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
Local Individualised End of Life
Care Plan for the dying adult
Insert local copy
Review Sheet
Years to live
Holistic Assessment
Name:_________________________
Advancing disease
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□ Holistic Assessment
Increasing decline
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□ Holistic Assessment
Last Days of Life
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First Days after Death
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recorded
□ Key/Lead worker nominated □
Offered
In place
□ Verification of death
bereavement
□ Follow-up
contact
□ Advance Care Plan review
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□ Certification of death
to bereavement
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□ Signpost
counselling services if required
Advance Care Plan:
Offered
In place
□ Family discussion
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Anticipatory drugs
□ prescribed and available
Assessment carried out by:
Family discussion
Assessment carried out by
District Nurse
Assess equipment needs
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GP
DN
Continuing health care
□ funding review
□ Assess equipment needs
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OOH DN
Anticipatory drugs available
Syringe driver available
Ambulance service updated
□ Bereavement leaflet
Is there an End of Life Care Plan
What to do ‘After a Death’
(or equivalent) in place
Booklet
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Out of Hours handover form
completed:
OOH GP
OOH DN
Is it known if Out of Hours
handover form has been
completed:
OOH GP
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□ DNACPR in place
Advance Care Plan:
Advance Care Plan wishes
Bereavement
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□ GP Assessment
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Complete Post Death
□ Information Audit Form
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□ Inform all relevant health
and social care professionals
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Is ambulance service updated
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Significant Event Analysis
Support for staff
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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
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
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
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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
Break time…
What is an appropriate hospital
admission at end of life?
HOME
HOSPITAL
RISKS- Anything that cannot RISKS- unfamiliar people,
be done in the home
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
Significant Event Analysis (SEA)
The importance of reflection
Significant Event Analysis
• What went well?
• What did not go well?
• What could have been done better?
• What would you have done differently?
Planning individual care
INDIVIDUAL’S NAME:
DATE:
Anticipated problems
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
NHS NUMBER:
DOB:
CARE PLAN: The person is approaching end of life:
Actual problems - DATE
Goals
Actions - DATE
What do you do to prevent
inappropriate hospital admissions?
What can support decision making
at the end of life?
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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
Supporting Staff
• Extra physical work?
• Emotional stress
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Removing the taboo- the traffic lights
Its ok to show feelings
Supervision- could you use reflection?
Peer support
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?
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
Any questions?