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Name:……………………………….DOB:……………… Northern Devon Healthcare NHS Trust Hosp No:……………… NHS No:…………… Incorporating Community Services in Exeter, East and Mid Devon Personalised Care Plan for the Last Days of Life Medical Care Plan For use in inpatient areas Patient Name: Ward: Hosp No: Consultant Date of Birth: NHS No: (Medical plan to be discussed and agreed with nursing staff) Following assessment and agreement that all reversible causes for current condition have been considered; the multi-professional team has agreed that the patient is likely to die in the next few days. Remember to apply the principles of the Mental Capacity Act 2005 Recognition of dying has been discussed with the patient (where appropriate) and family/NOK including: Name: Patient or relationship to patient: Date & Time: This form must be completed by a member of the medical team after discussion with the senior doctor (Consultant in charge or specialist registrar). Name of doctor completing form Grade and bleep no. Signature Date/Time To be signed by senior doctor (Consultant in charge or specialist registrar) within 24hrs Senior Doctor Approved date: August 2014 Review date: November 2014 Grade Signature Page 1 of 5 Date/Time Lead: John Fletcher-Cullum Version: 1.0 Name:……………………………….DOB:……………… Northern Devon Healthcare NHS Trust Hosp No:……………… NHS No:…………… Incorporating Community Services in Exeter, East and Mid Devon This guidance is to aid the care of patients thought to be dying within the next few days. The patient’s care should be individualised to their specific needs. If advice is needed at any stage, contact a senior member of the team or the Palliative Care Team on ext 3642 (bleep 812 or 401) or out of hours 01271 347214 North Devon Hospice for North Devon, or Hospiscare helpline on 01392 688044 for East Devon. Recognition that the patient is dying This can be difficult and the decision should be made by the most senior clinicians (nurses and doctors) caring for the patient. Why do you consider the patient is likely to die in the next few days? Document diagnoses and relevant clinical features: Diagnoses: ……………………………………………………………….. ……………………………………………………………….. ……………………………………………………………….. ……………………………………………………………….. ……………………………………………………………….. Clinical features: Bedbound Comatose Semi-comatose Unable to take tablets Unable to take more than sips of fluid Reduced peripheral perfusion Cheyne-Stokes respiration Respiratory tract secretions Other: Have you considered reversible causes? Document below: ...................................................................................................... ..................................................................................................... ...................................................................................................... ..................................................................................................... ..................................................................................................... ...................................................................................................... Discuss with the healthcare team, all the investigations, interventions and treatments and discontinue any that will not promote comfort, dignity and peace. Document what has been stopped and why: Document what is being continued and why: Approved date: August 2014 Review date: November 2014 Page 2 of 5 Lead: John Fletcher-Cullum Version: 1.0 Name:……………………………….DOB:……………… Northern Devon Healthcare NHS Trust Hosp No:……………… NHS No:…………… Incorporating Community Services in Exeter, East and Mid Devon Treatment Escalation Plan (TEP) Document which (if any) observations should be made: All patients should be medically reviewed regularly to check they are comfortable and not distressed. Consider the patient’s need for ongoing observations. TEP completed Yes Heart rate Yes No BP Yes No Respiratory rate Yes No Temperature Yes No Oxygen saturations Yes No Blood sugar Yes No No Does the patient have an Implantable Cardiac Defibrillator (ICD)? Yes No Record action to be taken to deactivate ICD Document who should be contacted if the observations are abnormal: …………………… ...……………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. Patient preferences and advance decisions Does the patient have: An advance decision to refuse treatment (ADRT)? Yes Record of actions/decisions No A Lasting Power of Attorney (Health and Welfare)? Yes No An express wish for organ/tissue donation? Yes No Any other wishes regarding care? Specify………………………………………………………… ………………………………………………………………… ………………………………………………………………… ………………………………………………………………… Approved date: August 2014 Review date: November 2014 ...……………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. ………………………………………………………. Page 3 of 5 Lead: John Fletcher-Cullum Version: 1.0 Name:……………………………….DOB:……………… Northern Devon Healthcare NHS Trust Hosp No:……………… NHS No:…………… Incorporating Community Services in Exeter, East and Mid Devon Symptom management Consider and address possible symptoms For example, pain, shortness of breath, nausea, vomiting, restlessness, confusion, urinary retention, dry mouth etc. Document current symptoms: Pain (including sites of pain) Shortness of breath Nausea Vomiting Consider whether any of these symptoms are reversible For instance confusion caused by opioid toxicity/hypercalcaemia or abdominal pain and restlessness caused by urinary retention. Restlessness Confusion Urinary retention Dry mouth Respiratory tract secretions Prescribe medications on the drug chart which may be required PRN and give reasons for use. Emotional and/or Spiritual Distress Other ………………………………………… Consider non pharmacological interventions for all symptoms Referral for support from other teams as indicated e.g. chaplaincy If unable to swallow oral medication convert to parenteral route (this will often be subcutaneous in a syringe driver) See symptom control guidelines for advice on conversions Patients who are thought to be dying should usually be prescribed medication for the relief of pain, nausea, vomiting, restlessness and respiratory tract secretions, unless there are contraindications. This means that symptoms can be controlled without delay even if they arise overnight. For advice on appropriate pre-emptive prescribing, see flow charts and/or symptom control guidelines on BOB Prescribing with severe/end stage renal failure (eGFR<30) can be complex and advice should be sought. Palliative care section on BOB contains the Renal LCP for guidance in prescribing in this area Consider using a syringe driver for patients who need regular SC medication for the control of pain or other symptoms. Approved date: August 2014 Review date: November 2014 Page 4 of 5 Lead: John Fletcher-Cullum Version: 1.0 Name:……………………………….DOB:……………… Northern Devon Healthcare NHS Trust Hosp No:……………… NHS No:…………… Incorporating Community Services in Exeter, East and Mid Devon Advice and guidance are available from: Senior members of the team looking after the patient The Hospital Palliative Care Team on 3642 (bleep 812 or 401) Out of hours – North Devon Hospice 01271 347214 or Hospiscare 01392 688000 Palliative Care guidelines (copy on ward and on BOB) Sensitive communication with the patient and/or family Record of discussion to include: 1. Explanation that the patient is now dying and why you think the patient is likely to die in the next few days 2. Explanation of what is happening and how death might be expected to occur. (This will be many peoples 1st experience of death of a loved one) 3. Explanation of the basis for your judgement. 4. That the patient and/or family have been offered the opportunity to ask questions and be involved in decisions about care. Discuss resuscitation decision sensitively (if appropriate). Discuss priorities for care, including place of care (if appropriate). Even very ill patients may be discharged home, if they and their family wish.(Consider how we can bring home to them; if too unwell to transfer) Discuss the use of medication for symptom management. If a syringe driver is necessary this needs to be discussed with the patient (if appropriate) and their family. Explain that patients, who are able to, should be offered, encouraged and helped to eat or drink. If a patient’s swallowing is impaired they are at risk of aspiration pneumonia. They may still choose to take sips and this should be reviewed on an individual basis to maximise overall comfort. Discuss the role of artificial nutrition and hydration if appropriate. Explain the potential risks and benefits of artificial hydration and nutrition in the dying.(Including reduced need and wish for food and fluid when dying) Document the conversation, including all the issues above (use continuation sheet if needed): NB if already documented in the medical records, please reference date and time of the discussion. Name of doctor completing form: Approved date: August 2014 Review date: November 2014 Grade and Bleep No Signature Page 5 of 5 Date/Time Lead: John Fletcher-Cullum Version: 1.0
