Download North Derbyshire Care Pathway for the Last Days of Life

North Derbyshire Care Pathway for the Last Days of Life
NAME
NHS No
___________________
___________________
DoB
Start Date
___________________
___________________
This Care Pathway has been developed to assist clinicians with caring for patients in the terminal phase
of their disease.
It consists of a series of questions, which may be answered by any of the multi-disciplinary team
attending the patient. It is intended as a guide based on knowledge of the terminal phase and the
symptoms likely to develop. The pathway sets out standard practice for all carers on one document.
Variations in clinical judgement are perfectly acceptable. These should be documented on the variance
form and appropriate action taken if needed which will ultimately improve care.
The pathway is a legal document and is part of the patient’s health care record.
Throughout the care pathway the term ‘Organisation’ refers to all NHS Trusts, PCT’s Independent and
Private establishments and Acute Hospitals and their successors in North Derbyshire.
Community
Hospital
District Nurse/Nurse Practitioner
Name
Phone no.
General Practitioner
Name
Phone no.
Consultant
Ward
OTHER USEFUL NUMBERS
NAME
NUMBER
ORGANISATION
INSTRUCTIONS FOR USE
1.
All goals are in heavy typeface. Interventions, which act as prompts to support the goals are in
normal type. Things to consider are in italics.
2.
If a goal is not achieved (i.e. variance) then record on the variance section of the back page.
3.
The Palliative Care Symptom Guidelines are printed on the pages at the end of the pathway.
Please make reference as necessary.
4.
The Pathway cannot be acted upon until Section 1 is completed and signed by a Doctor and a
Registered Nurse.
5.
To contact the Specialist Palliative Care Team – at the Royal Hospital via Ext 2693 – In
Community settings ring 01246 568801 – out of hours Medical on call via Royal Hospital
switchboard 01246 277271.
CRITERIA FOR USING THE CARE PATHWAY
The multidisciplinary team must agree that the patient has an incurable life limiting illness and an
expected prognosis of less than one week. In addition, 2 of the following criteria should apply.
The patient is:
Essentially bed bound
Increasingly drowsy
Finding it difficult to swallow
(Oxford textbook of Palliative Medicine 1995 Twycross R & Lichter I. P651)
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
-1-
NAME
DoB
NHS No.
Or Patient Identification Label
ALL PERSONNEL COMPLETING THE CARE PATHWAY PLEASE SIGN BELOW
Name (Print)
Full Signature
Initials
-2-
Professional Title
Date
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
NHS No.
Or Patient Identification Label
SECTION 1
PATIENT ASSESSMENT
COMFORT
MEASURES
If ‘No’ chart as variance on the back page
GOAL 1: MEDICAL TREATMENT AIMED AT SHORT TERM COMFORT
YES
NO
A: Is the patient taking only medication which is aimed at
maintaining or improving short-term comfort?
YES
NO
If ‘No’, can any of these be stopped?
E.g. Anticoagulants; antibiotics; anti-arrhythmics; anti-hypertensives;
hypoglycaemics; replacement hormones; statins.
OUTCOME: THE PATIENT IS NOT TROUBLED BY TAKING NON-ESSENTIAL
MEDICATION
YES
NO
YES
NO
B: Is the patient’s medication reliably or comfortably
taken by the best route?
If ‘No’ has the prescriber looked at alternatives?
E.g. liquid form, S/C medication, rectal, transdermal, nebulised, via feeding tube,
sublingual?
OUTCOME: THE PATIENTS SYMPTOMS ARE MANAGED WITH MINIMAL DISTRESS
TO THE PATIENT.
C: The patient is at risk of developing symptoms.
YES
Do they have access to as required medication by an
appropriate route?
E.g.
s/c diamorphine/oxycodone – for pain
s/c haloperidol – for nausea/agitation
s/c hyoscine butylbromide – for retained secretions
Consider conversion to a Palliative Care Prescription Card
Consider conversion to a syringe driver
NO
OUTCOME: THE PATIENTS SYMPTOMS ARE MANAGED WITHOUT DELAY
CLINICAL
INTERVENTION
GOAL 2: CLINICAL INTERVENTION AIMED AT PATIENT COMFORT
A: Is the patient receiving any intervention which is not aimed at patient comfort?
E.g.
Routine blood tests
Gastrostomy feeds
Nasogastric tube
TPR/BP/O2 sats
IV (fluid/medications)
Subcut fluids
YES
NO
Would stopping/removing these reduce distress?
OUTCOME: PATIENT COMFORT IS MAXIMISED WITH MINIMAL DISTRESS
PSYCHOLOGICAL
INSIGHT
GOAL 3: INTERVENTIONS AIMED AT MAXIMISING PATIENT/CARER
UNDERSTANDING OF THE TERMINAL PHASE, WHILST MINIMISING FEAR
AND DISTRESS
YES
NO
A: Have you reviewed the patient/carer’s understanding
of disease progression?
Provide time to discuss patient’s understanding, fears, expectations and wishes
Nutrition
Consider notifiable diseases
Consider industrial disease
Prepare carers for retained secretions; Cheyne Stokes breathing; fluctuating
coma; maintained awareness during comatose periods.
OUTCOME: THE PATIENT/CARER HAS HAD AN OPPORTUNITY TO DISCUSS THE
SITUATION AND PLAN OF CARE
-3-
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
Or Patient Identification Label
SECTION 1
PSYCHOLOGICAL
INSIGHT
(Continued)
NHS No.
PATIENT ASSESSMENT
YES
NO
B: Have you checked whether there are people the
patient wishes to see or to be with?
This allows the patient the opportunity to deal with unfinished business.
Provides time to discuss issues – family, friends, religious representatives, legal
representatives.
OUTCOME: THE PATIENT FEELS AT PEACE AND IS ABLE TO DEAL WITH
UNFINISHED BUSINESS
YES
NO
C: Are you clear about the patient’s wishes regarding
their care leading up to and following death?
Provide time to discuss specific wishes e.g. visiting needs; preferred place of
care; cultural needs; spiritual needs; care of the deceased person; organ
donation; funeral request.
Document specific wishes below
OUTCOME: THE PATIENTS WISHES ARE REALISED AND CAN BE BUILT INTO THE
CARE PLAN.
D: Have you provided the family/carers* with the
YES
NO
necessary information regarding who to contact
following death?
E.g. In community – GP, In hospital – Bereavement Service
Pathway explained and discussed with
a) Patient
b) Family
c) Carers
d) Not
discussed
Family/Carer express understanding of Pathway
YES
NO
N/ A
OUTCOME: THE FAMILY ARE AWARE WHO TO CONTACT FOLLOWING DEATH
RESUSCITATION
For Primary and
Secondary care
settings
Agreed NOT to resuscitate – according to Organisational Guidelines
Complete the appropriate Organisational documentation
This patient is imminently dying. Attempts at CPR would not benefit them
therefore DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION.
Doctor’s signature
Contact or Bleep No.
Doctors Name (please print)
Date
If a decision to resuscitate is made, then discontinue the pathway, and
complete the variance.
If the patient moves to another care setting this decision must be discussed
with the new responsible doctor, reviewed as soon as possible, and this
section must be completed again.
OUTCOME: THE PATIENT IS NOT SUBJECTED TO INAPPROPRIATE PROCEDURES
COMMUNICATION
WITH OUT OF
HOURS
SERVICES IN
COMMUNITY
GOAL 4: OUT OF HOURS AND EMERGENCY SERVICES ARE INFORMED
OF THE PATIENT’S CONDITION
Handover/Critical Care/Summary sheet faxed to
YES
NO
Derbyshire Healthcare/NHS Direct/EMAS/Other
Agencies as relevant?
OUTCOME – THE PATIENT AND CARERS RECEIVE PROMPT AND APPROPRIATE
OUT OF HOURS CARE
COMPLETION
Doctor’s signature
SECTION ONE COMPLETED
Date
Print Name
Nurse’s signature
Date
Print Name
* Family/Carers refers to all important relationships with the patient.
-4-
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
NHS No.
Or Patient Identification Label
Codes (Please enter in columns) A = Achieved or V = Variance and Initial each box. In Inpatient areas this must be
completed at least 4 hourly e.g. 0800, 1200, 1600, 2000, midnight and 0400 hours. In Home settings complete at
regular intervals as appropriate.
Section 2
FOCUS OF PATIENT CARE
Date
Time
ASSESSMENT OF PAIN/COMFORT
MEASURES
PAIN
Goal 5: Patient is pain free
-
Verbalised by patient if conscious
Pain free on movement
Appears peaceful
Move only for comfort
AGITATION
Goal 6: Patient is not agitated
- Patient does not display signs of delirium,
terminal anguish, restlessness (thrashing,
plucking, twitching)
- Exclude retention of urine as cause
RESPIRATORY TRACT SECRETIONS
Goal 7: Patient’s breathing is not made
difficult by excessive secretions
NAUSEA & VOMITING
Goal 8: Patient does not feel nauseated or
vomits
- Verbalises if conscious
OTHER SYMPTONS (e.g dyspnoea)
a)
b)
ESSENTIAL CARE
PERSONAL HYGIENE
Goal 9: Patient feels (or appears) fresh &
comfortable
- Hygiene needs are addressed regularly
Take into account personal dignity and privacy
MICTURITION DIFFICULTIES
Goal 10: Patient is comfortable, clean and
dry
- Urinary catheter if in retention as per policy
Continence Management if general weakness
creates incontinence.
BOWEL CARE
Goal 11: Patient is not agitated or
distressed due to constipation or diarrhoea
Constipation can lead to retention of urine and
diarrhoea (see Goal 10)
MOUTH CARE
Goal 12: The patient has a moist
comfortable mouth
-
Use a small soft headed toothbrush and paste.
If not tolerated or gums damaged use foam stick
Dentures removed and cleaned
Mouthwashes/oral treatments as prescribed
Apply white paraffin to lips
IMMOBILITY
Goal 13: Patient is comfortable, in safe
environment
- Change position as appropriate
- Use appropriate equipment, consider pressure
relief
MEDICATION
Goal 14: All medication is given safely and
accurately according to Organisational
Policy
If syringe driver in progress check & change
according to Organisational Policy
-5-
Date
Time
Date
Time
Date
Time
Date
Time
Date
Time
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
NHS No.
Or Patient Identification Label
This section to be completed as appropriate – at least once to twice daily
(Please enter in columns) A = Achieved or V = Variance and Initial each box
PSYCHOLOGICAL / INSIGHT / SUPPORT
Date
Time
Date
Time
Date
Time
Date
Time
PATIENT
Goal 15: Patient is aware of the situation as appropriate
- Patient is informed of procedures
- Touch and verbal communication are important
FAMILY / CARERS*
Goal 16: Family/Carers* are prepared for the patient’s
imminent death with the aim of achieving peace of mind and
acceptance
-
Check understanding
Recognition of patient dying
Inform of measures taken to maintain patient’s comfort
Explain possibility of physical symptoms e.g fatigue
Psychological symptoms such as anxiety/depression
Social issues such as financial implications
Goal 17: The needs of those attending the patient in
hospital/nursing/residential homes are accommodated
The family/carers* are informed of available facilities, including carer’s
room if appropriate
RELIGIOUS / SPIRITUAL SUPPORT
Goal 18: Appropriate religious / spiritual support has been
offered
COMMUNICATION
Goal 19: Update other services / out of hours services of any
changes relevant to them.
IF YOU HAVE CHARTED “V” AGAINST ANY GOAL SO FAR, PLEASE COMPLETE VARIANCE
SHEET AT THE BACK OF THE PATHWAY BEFORE INITIALLING ABOVE
Repeat this page as needed
MULTIDISCIPLINARY PROGRESS NOTES
* Family / Carers refers to all important relationships with the patient
-6-
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
NHS No.
Or Patient Identification Label
VERIFICATION OF DEATH
Date of death:
__________________________________
Time of death
___________
Persons Present
_____________________________________________________________
Additional Information
_____________________________________________________________
___________________________________________________________________________________
SECTION 3
CARE AFTER DEATH
Goal 20: GP Practice contacted re patients death
Date
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Goal 21: Other agencies contacted regarding patients death e.g
District Nurse
Marie Curie Nurse
Community Macmillan Nurse
Social Services
Acute / Other Hospital Medical Records
Funding Nursing Care Team
Goal 22: Procedures following death discussed or carried out as
per patient wishes (see section 1, Goal 3C)
In Hospital
- Procedures for laying out followed according to
Organisational Policy
- Dealing with deceased checklist completed
Goal 23: Necessary documentation and advice is given to
appropriate person e.g
In Community
Contact funeral director
Registration of death
Bereavement Support Information
What to do After Death Booklet (D49)
Contact Mediquip/Supplier to arrange collection of equipment
Return all medication to Chemist (Except care homes)
In Hospital
Family/Carer* given Bereavement Service Card and Trust
Bereavement Booklet
Trust Policy followed for Patients valuables and
belongings
Bereavement Service Information Leaflet Completed
Property and Completed Leaflet collected by Bereavement
Service
IF YOU HAVE CHARTED ‘NO’ AGAINST ANY GOAL SO FAR, PLEASE COMPLETE VARIANCE
SHEET AT THE BACK OF THE PATHWAY BEFORE SIGNING BELOW
Nurses Signature _____________________________________________
Date
_____________________________________________
*Family / Carers refers to all important relationships with the patient
-7-
NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAME
DoB
NHS No.
Or Patient Identification Label
VARIANCE ANALYSIS FOR LAST DAYS OF LIFE
G.P
____________________________________
DATE OF DEATH
____________________________________
If a variance is noted please ensure that it is reviewed within 24 hours
DATE
WHAT VARIANCE
OCCURRED?
WHY DID
VARIANCE
OCCUR?
-8-
ACTION TAKEN
INITIALS
TITLE
SYMPTOM MANAGEMENT GUIDELINES FOR THE NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
PAIN
YES
Is the patient already taking morphine or other strong opioids?
Continuous s/c diamorphine
Calculate the 24 hour dose of oral morphine, divide the total dose by 3, which is the
equivalent dose of diamorphine over 24 hours s/c via syringe driver – e.g patient on 90mg
Zomorph BD = 180mg oral morphine over 24 hours, which equals 60mg diamorphine s/c
over 24 hour infusion.
Transdermal Fentanyl
If the patient is using transdermal fentanyl but now has uncontrolled pain, continue the
fentanyl and use appropriate dose s/c diamorphine as required in addition. See
guidelines.
Breakthrough Analgesia
To calculate the breakthrough dose of diamorphine divide the 24-hour dose of
diamorphine in the syringe driver by 6. e.g if the patient is receiving 60mg diamorphine s/c
over 24 hours the breakthrough dose of diamorphine is 10mg s/c p.r.n
Alternatively
Morphine oral liquid may be used if the patient is taking sips of fluid. To calculate the
equivalent oral morphine breakthrough dose, multiply the s/c breakthrough dose by 3 e.g.
s/c diamorphine 10mg for breakthrough up to hourly = 30mg oral morphine for
breakthrough.
NO
Has the patient got pain?
YES
NO
As required medication
1. Diamorphine 2.5mg s/c p.r.n
2. Morphine sulphate 5mg orally
p.r.n
1. Diamorphine 2.5mg stat
2. Diamorphine 10mg/24
hours via s/c infusion.
3. Diamorphine 2.5mg s/c
p.r.n
To calculate the subsequent doses of diamorphine over 24 hours
Review the doses of p.r.n analgesia given in the previous 24-hour period. If more than one dose has been required, other than to pre-empt during care (e.g before a dressing etc) then
consider a 30% to 50% increase in the daily subcutaneous dose.
If this is not controlling the pain, or doses need escalating on a daily basis seek specialist advice.
If diamorphine is unavailable or the patient has previously been on oral oxycodone use the same calculation format as above using Oxycodone.
Diamorphine 1mg:Oxycodone 1mg
For further information see the additional conversion sheet attached
IF SYMPTOMS PERSIST SEEK SPECIALIST ADVICE
-9-
SYMPTOM MANAGEMENT GUIDELINES FOR THE NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
RETAINED SECRETIONS
Present
Absent
1. Explain to relatives that for the patient retained
secretions are not bothersome due to decreased
sensitivity of pharynx.
IF the relatives are concerned or the patient appears
distressed:
2. Hyoscine butylbromide 20mg s/c stat.
3. Hyoscine butylbromide 60mg / 24 hours via s/c
infusion.
4. Hyoscine butylbromide 20mg s/c hourly p.r.n.
As required medication
Hyoscine butylbromide 20mg s/c
IF SYMPTOMS PERSIST SEEK SPECIALIST ADVICE
- 10 -
SYMPTOM MANAGEMENT GUIDELINES FOR THE NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
TERMINAL RESTLESSNESS AND AGITATION
Present
Absent
As required medication
1. Exclude treatable causes
Pain
Retention of urine or faeces
Hypercalcaemia if would be appropriate to treat
2a Delirium
2b Anxiety/Dyspnoea
1. Haloperidol 2.5mg stat
2. Haloperidol 5mg/24hrs
via s/c infusion
3. Haloperidol 2.5mg s/c
p.r.n
1. Midazolam 2.5mg s/c
stat
2. Midazolam
10mg/24hrs via s/c
infusion
3. Midazolam 2.5mg s/c
p.r.n
Review every 24 hours
Increase the dose of Haloperidol
to 10mg/24 hours via s/c
infusion if necessary.
N.B A total dose of
15mg/24hours – including stat
dose, continuous dose and p.r.n.
doses should not be exceeded.
Haloperidol 2.5mg s/c p.r.n
Review in 24 hours
Review every 24 hours
Increase the 24 hour dosage
according to the total dose of
Midazolam given on a p.r.n
basis up to a total dose of
10mg.
IF SYMPTOMS PERSIST SEEK SPECIALIST ADVICE
- 11 -
SYMPTOM MANAGEMENT GUIDELINES FOR THE NORTH DERBYSHIRE CARE PATHWAY FOR THE LAST DAYS OF LIFE
NAUSEA
YES
Previously on anti emetic
Convert to s/c as
appropriate
NO
YES
Nausea present
1. Haloperidol 1.5 – 2.5mg s/c stat
2. Haloperidol 5mg via s/c infusion
3. Haloperidol 1.5 – 2.5mg s/c p.r.n
NB A total of 15mg / 24 hours –
including stat doses, continuous s/c
doses and p.r.n. doses – should not be
exceeded
Review in 24 hours
Increase to 10mg/24 hours s/c if nausea persists
For persistent nausea switch to:
1. Levomepromazine (Nozinzn) 6.25mg/via s/c infusion
2. Levomepromazine 6.25mg p.r.n s/c
N.B A total of 50mg/24 hours – including continuous and p.r.n doses – should not be exceeded
- 12 -
NO
Prescribe
So available if needed
Haloperidol 1.5 – 2.5mg
s/c p.r.n (up to a total of
15mg/24 hours)
PALLIATIVE CARE DOSE CONVERSION CHART
Morphine
4 hourly
Zomorph
or MST
b.d.
MXL o.d.
Oxynorm
4 hourly
Oxycontin
b.d.
Oxycodone
SC in 24
hours
Diamorphine
or Oxynorm
s/c 4 hourly
Diamorphine
s/c in 24
hours
Fentanyl
patch 72
hourly
10 mg
30mg
60mg
5mg
15mg
20mg
5mg
20mg
25mcg
20mg
60mg
120mg
10mg
30mg
40mg
5mg
40mg
25-50mcg
30mg
90mg
180mg
10mg
40mg
60mg
10mg
60mg
50mcg
40mg
120mg
240mg
20mg
60mg
80mg
15mg
80mg
50-75mcg
50mg
150mg
300mg
20mg
70mg
100mg
20mg
100mg
75-100mcg
60mg
70mg
80mg
180mg
200mg
240mg
360mg
400mg
480mg
30mg
30mg
40mg
90mg
100mg
120mg
120mg
140mg
160mg
20mg
20mg
30mg
120mg
140mg
160mg
90mg
100mg
260mg
300mg
540mg
600mg
40mg
50mg
130mg
150mg
180mg
200mg
30mg
30mg
180mg
200mg
110mg
120mg
140mg
330mg
360mg
420mg
660mg
720mg
840mg
50mg
60mg
70mg
160mg
180mg
200mg
220mg
240mg
300mg
40mg
40mg
50mg
220mg
240mg
300mg
160mg
480mg
960mg
80mg
240mg
320mg
60mg
330mg
180mg
540mg
1080mg
90mg
250mg
360mg
60mg
360mg
100mcg
125mcg
125150mcg
150mcg
150175mcg
175mcg
200mcg
225275mcg
250275mcg
300mcg
- 13 -
Buprenorphine
patch 72
hourly
35 - 52.5
mcg
52.5-70
mcg
87.5 –
105 mcg
105122.5
mcg
122.5140 mcg
Hydromorphone
4 Hourly
Hydromorphone
SR b.d.
1.3mg
4mg
2.6mg
8mg
3.9mg
12mg
5.2mg
16mg
6.5mg
20mg
7.8mg
9.1mg
10.4mg
24mg
28mg
32mg
11.7mg
13mg
36mg
40mg
14.3mg
15.6mg
18.2mg
44mg
48mg
56mg
20.8mg
64mg
23.4mg
72mg