Download Shorter version LaDoL guidance - Derbyshire Alliance for End of

Guidance for the care of patients who are approaching the last
days of their lives
Patient deteriorating and likely entering last days of life
Signs include becoming increasinglybedbound, drowsy, disorientated, weak, dependant and finding it hard to swallow and take medications
Decisions MUST HAVE SENIOR RESPONSIBLE CLINICIAN INPUT
ALL REVERSIBLE CAUSES MUST HAVE BEEN FIRST CONSIDERED
Speak with patient and family
Ensure that the patient if able and those close to them are fully involved in the decision making process, have been
informed of the current situation, and proposed plan of management. Allow time/opportunity to express the known
wishes of the patient and those of the family.
(see communication section for further advice)
Does patient have any specific wishes
Review medication and ensure treatment is appropriate for current situation
Prescribe anticipatory drugs
Assess need for medically assisted hydration and nutrition
Ensure has DNACPR in place
Does patient have specialist palliative care needs
This might include pain or symptoms that are not easily controlled or support for the patient or those close to them.
If yes refer to hospital team
Ring 2693 and leave message
For urgent referrals bleep 099, 097, 571, 570, or 642
Out of hours advice via hospital switchboard (Request page on-call palliative SPR)
Preferred place of care
If patient is suitable for discharge, where do they want to be ?
Hospital
Other
Start LADOL patient daily chart
Clarify wishes with patient and family, if
discharge viable option complete fast
track documentation
Nurses to speak with family and ensure
fully understand plan of care, have
opportunity to raise concerns and are
aware of carer communication sheet and
its uses
liaise with discharge team and follow fast
track discharge policy and liaise with
appropriate services/community partners
NB Please refer to palliative care team for
assessment of suitability for referral for
hospice care
NB this document does not replace good clinical decision making for the individual
patient it serves as guidance only.
Patient assessment/ Care planning
After identification that the patient is likely in the last days of life then a more
detailed assessment and interaction with the patient and family should take place
Areas to be covered include●Specific patient wishes
●Unfinished business
●Place of care
●Family requests
●Review of medication
●Identification of main contact
●Religion and culture
●Preservation of Privacy and dignity
●Issues surrounding mental capacity
●Review of clinical interventions including
medically assisted hydration and nutrition,
DNACPR status
●Organ donation
From the assessment a detailed plan of care is formulated that is tailored and responsive to each
individual patients needs and wishes.
If patients are no longer able to decide for themselves through lack of capacity or ill health then
families need to be asked what they think the patient would have wanted
Further guidance on the assessment process can be found on the palliative care tab on ward carts
or in the resource file situated in every ward area.
Note the GMC guidance (2010) Treatment and care towards the end of life: good practice in
decision making provides more detailed advice.
Using the LaDoL bundle
The LaDoL bundle is based on the recommendations of the Leadership Alliance for
the care of dying people "one chance to get it right". It has been designed to help
healthcare professionals provide high quality care and support to patients who are
thought to be in the last days of their lives.
Components
●LaDOL patient daily chart
●Patient guidance booklet
●Palliative care PRN bundle on JAC
●Ward resource file (Nursing)
●Checklists for Health Care Professionals
●Patient relative information leaflet
● Assessment and prescribing guidance on palliative
care tab (ward carts)
NB To be used in conjunction with usual nursing and medical documentation
Underpinning principles
Timely identification
Patients whose condition undergoes serious change must be identified and assessed promptly. If
the change is reversible then, with consideration for the patients wishes, treatment focus should
be on maintaining life and wellbeing. Where the change is irreversible then the focus should move
towards preserving comfort and dignity. The appropriateness of use of the LADOL bundle is
reviewed whenever any change occurs or at least every day.
Using the LaDoL bundle
UNDERPINNING PRINCIPLES
Communication
It is essential that patients and those close to them are fully informed in a way that is easily
understood, are involved in the planning of care and have the opportunity to discus their
concerns, wishes and preferences about care and treatment.
There should be regular sensitive communication with those close to the patient, its especially
important that any changes in condition or how we are managing care are passed on to the
family.Identify where possible who the patient wishes to be informed of any condition changes and
ensure their contsct details are checked.
All communication and descisions made must be carefully documented.
.
Carer Support
Named nurse for each shift is responsible for ensuring that the patient/family understand the
situation, know of any changes to mangement and have had opportunity to voice any
concerns/questions.
It is important that we enable the patients family to spend time with them and feel part of the care.
We need to recognise this as a difficult time for relatives and should assess their needs and
signpost to support, such as their GP, health psychology etc.
Ensure available written information is offered.
Give information about overnight accomodation, open visiting facilities and car parking
Carer Communication Sheet
At each interaction with the patient check for any new information left on the carer communication
sheet, please insure any questions posed there have been answered and discussed with the
patients family.
Privacy & Dignity
Ensuring privacy and dignity is respected is an essential component of care. Where possible a
side room should be offered if not possible then this should be explained and documented.
All interventions are planned with the individual patient in mind respecting their individual wishes,
their situation and their needs.
Coordination
Every patient must have senior responsible clinician or consultant who is clearly identified on the
open ward electronic notice board.
An identified named nurse each shift, is named on the daily record sheet
You should seek specialist advice if needs are complex and or beyond your limits of competence
Ongoing assessment
Patient checks are carried out between 1 and 4 hourly, dependant on the needs/wishes of patients
and their relatives.
Relatives often value time with their loved one but it can be a lonely and frightening time and some
families may prefer frequent checks and some may not want disturbing often.(identify and
document if any preference).
Ensure relatives are aware of how to call for assistance.
Each day an assessment must be performed by a Doctor to ensure that the focus of care remain
appropriate, if a patients condition has improved then the level of care they are receiving must be
considered (document and discuss with the patient and /or their family).
Ongoing Assessment
At each assessment consider the following interventionsPRIVACY & DIGNITY
●Consider side room
- offer if available acknowledge/explain if not
●Ensure you are aware of patient and family's
preferences
●Pay attention to appearance i.e. brush hair
●Ensure is adequately covered
●Never speak over the patient
MOUTH CARE
●Give as frequently as possible
-Use foam stick soaked in water /juice or preferred
beverage
-Apply white paraffin to lips.
●Use Saliva replacement spray/gel
●Instruct and assist family if they wish to be
involved
● Chart when given
PRESSURE AREAS/POSITION CHANGES
●Reposition for comfort
●Consider if patient has position of preference
-Is balance between skin integrity and patient comfort
●Describe pressure areas daily on patient
chart
●Ensure appropriate pressure relieving
equipment used
●Chart each position change
PERSONAL HYGIENE
●Assess if is clean and dry
●Offer bed bath at least once each day
-Aim is to ensure patient is clean/fresh without
causing distress
●Chart when any intervention given
●Chart if patient/family request no input
ELIMINATION
●Check is clean and dry
●Manage continence using pads urinary sheath
● Chart urinary output and bowel actions
●Urinary retention and /or constipation can
cause distress, pain and agitation
-If so consider urinary catheter and/or PR
intervention
ASSESSMENT OF SYMPTOMS
●Score the severity of the symptom at each
assessment
-with 0 = absent 1 = low 2 = moderate 3 = severe
●Ask patient where able to respond
●Ask family how settled they feel patient is
●Always consider reversible causes such as
constipation. positioning, urinary retention
●This enables ongoing assessment of
symptoms over time
-allowing changes to medication to make
sure that the patient has the best control of
symptoms possible
● Chart score at each review
Observe for signs of PAIN
●Grimace ●frown ●groaning ●restlessness
●pain on movement
●If in pain give PRN analgesia and document
effect
Observe for signs of AGITATION
●Hallucinations
●Restlessness
●Disorientation
●Thrashing
●If agitated give PRN anti-psychotic and
document effect
Ongoing Assessment
At each assessment consider the following interventionsObserve for signs of RESPIRATORY TRACT SECRETIONS
●Noisy audible breathing -may be more distressing
to family than for patient
●Positioning and use of suction is also important
●Chart score at each review
●If problematic give PRN anti-spasmotic and
document effect
Observe for signs of NAUSEA &VOMITING
●Retching ●hiccups ●chart any occurrence
of vomiting
●If problematic give PRN anti-emetic and
document effect
Observe for signs of BREATHLESSNESS
●Fast or laboured breathing -oxygen should
only be used for patient comfort nasal
canulae is often sufficient
●If problematic give PRN medication and
document effect
PRN MEDICATION & SYRINGE DRIVERS
●Use separate chart to record and monitor
use of syringe driver
●If has symptoms give prn medication and
monitor effect, if not resolved after 1 hour or
symptom persistent than redose
●If needing more than 1-2 doses in 24 hour
period then ensure medical team are aware
as may need to increase/commence syringe
driver
EATING &DRINKING
●Ensure all patients who are able to eat and
drink are offered small frequent drinks and
soft diet -Chart input
●If unsafe swallow need to decide and
document if appropriate to comfort feed
accepting increased risks of aspiration
CLINICALLY ASSISTED HYDRATION/NUTRITION (CA N/H)
●Status of hydration/nutrition must be reassessed
each day
●If CA N/H
insitu must decide if giving benefit, if no benefit or
may be causing issues such as oedema etc then
need to consider stopping.
●if CA N/H not in place then need to decide if
may be of benefit i.e. may help with confusion
agitation
COMMUNICATION
●Check understanding
●Explain the situation
●What to expect
●How to alert staff to any problem or issue ●Inform
re facilities and support services
●Check aware of carer communication sheet
●Touch is an important method of
communication in those who cannot verbally
communicate Support may be needed with
social/financial issues, anxiety/depression
frustration and anger are common people for
experiencing loss
LIAISON WITH MEDICAL TEAM
●Medical team should check and respond to patient daily chart and carer communication sheet at
least daily
●refer to palliative care if any issue beyond scope of competence/any uncertainty or if patients
symptoms have not settled within 24hours
Management of Symptoms
Symptom
Pain
Agitation
Secretions
Actions
Aim- Patient is pain free
●Can use liquid opiod if able to swallow
●If usually on strong opioid and unable/finding it difficult
to swallow will need to convert to syringe driver - see
dose conversion chart for details of how to do this
●To calculate PRN analgesia dose divide total daily dose
by 6. i.e if on a syringe driver with 30mg diamorphine over
24 hours then PRN dose will be 5mg Diamorhine S/C
●Standard doses on JAC
Paracetamol 1g oral or IV
Diamorphine* 2.5-5mg S/C PRN
Oramorph* 5-10mg orally PRN (in pts able to
swallow)
(May be given at higher doses*)
●Other drugs that can be used where
Aim- Patient is not agitated
●First exclude reversible causes such as urinary retention,
constipation, pain, hypercalcaemia.
●Delirium is when patients are confused, disorientated
and may experience hallucinations
●Anxiety is when patients are oreintated but frightened,
upset and in turmoil
Standard doses on JAC
Midazalam* 2.5mg S/C PRN (Anxiety)
Haloperidol* 2.5mg S/c PRN (Delirium)
(May be given at higher doses*)
Aim- Patient or carer not distressed by patients
Standard doses on JAC
Hyoscine Butylbromide 20mg S/C PRN
excessive secretions
●Positioning may help either sitting up slightly or laying
on either side may help drain secretions from airways
●Suction can also be used if needed
Nausea
&vomiting
Breathlessness
Medication
Aim- Patient does not feel nauseated and is not
prescribed includeAlfentanyl, Oxycodone, Methadone, tramadol,
Fentanyl (nasal or buccal), ketamine, ketoralac,
clonazepam
●Other drugs that can be used where
prescribed includeLevomepromazine 6.25mg S/C, Olanzapine
(Anxiety) Diazepam, Lorazepam, Clonazepam
(Delerium)
●Other drugs that can be used where
prescribed includeGlycopyronium
Standard doses on JAC
Haloperidol 1.5-2.5mg S/C PRN
vomiting
●If previously on anti-emetic and having difficultly, cannot ●Other drugs that can be used where
swallow or is nauseated/vomiting then convert at same
prescribed includedose to a syringe driver
Levomepromazine 6.25mg S/C PRN (delirium)
Metoclopromide, Ondansetron, Granesetron
(anxiety)
Aim- Breathlessness is not distressing for the
patient
●For tachypnoea (rapid shallow breathing) use
diamorphine to slow and strengthen breathing
●For Anxiety/Distress use Midazalam to calm breathing
Standard doses on JACDiamorphine 2.5-5mg S/c PRN (rapid breathing)
Midazalam 2.5-5mg S/C PRN (anxiety/distress)
For rapid breathing as per pain relief
For anxiety/distress: ●Other drugs that can be
used where prescribed includeLorazepam, diazepam, Clonazepam
●If patient has ongoing pain or other symptom then ensure has had a medical review and where
appripriate has got a syringe driver or regular medication prescribed.
●It will take up to4-6 hours for a syringe driver to start to have effect, consider giving PRN
medication at setup if patient symptomatic
●It usually takes 20-30 mins for PRN medications to start to have any effect and up to 1 hour for
full effect to be reached, if symptoms not relieved in 1 hour then need to redose.
●To calculate subsequent doses review how much has been given in past 24 hrs if more than 1 or
2 doses (not pre-emptivley) then consider a 30-50% increase in regular dose.
●If patient unsettled for more than 24 hours request specialist palliative care team review