End of Life Care – draft

Last Updated on by frcemuser

clinical signs that death might be imminent, particularly if there is:

  • Refractory / progressive bradycardia
  • Mandibular movement with respiration
  • Deeply mottled skin / cyanosed peripheries
  • Noisy pharyngeal respiratory secretions (aka the “death rattle”)

The Jigsaw

  • The Patient and Their Family-
    • In the centre of the jigsaw is the patient as they are the centre of the ongoing care.
  • The Patient’s Wishes:
    • asking the patient or their family what their wishes are, we should try and establish if there are any existing decisions or statements of preference about the end of life care and plan accordingly.
    • Consideration should be given to any advanced care plans, resuscitation status orders, organ donation as well as a preferred place of the care-community anticipatory care plan, an advanced directive (aka “living will”), a ReSPECT form, a Lasting Power of Attorney for Health and Welfare or documentation held by the patient’s GP / care home /Electronic Palliative Care Coordination System (EPaCCS), Nominated decisions-makers (LPAs)
    • Note that a “Do Not Resuscitate” or DNACPR order only relates to CPR in the event of cardiac arrest. It does not proscribe / limit any other procedure or intervention and therefore fails to address other important end of life issues.
  • Spiritual Wellbeing
  • Continuing Care Needs: This may include mouth care, hydration and nutrition or pressure area care
    • Non-pharmacological techniques
    • Pharmacological therapies
      • MORPHINE 2mg s/c, hourly PRN – for pain and / or breathlessness
      • MIDAZOLAM 2mg s/c, hourly PRN – for anxiety / agitation
      • HYOSCINE BUTYLBROMIDE 20mg s/c, maximum of 6 doses in 24hrs – for secretions
      • LEVOMEPROMAZINE 2.5mg (two point five) s/c, 8 hourly PRN – for nausea
      • HALOPERIDOL 2mg s/c, 12 hourly PRN for agitation / delirium
  • Breaking Bad News
  • Emotional Support
  • Legal Issues
    • Lack capacity :
      • Once a patient is deemed to have lost capacity to make a decision about medical treatment, appropriate legal frameworks should be followed; in England and Wales the Mental Capacity Act (2005), in Scotland the Adults With Incapacity Act (2000), and in Northern Ireland the Mental Capacity Act (2016).
      • Have they written an Advance Decisions to Refuse Treatment? Have they appointed a Lasting Power of Attorney for Health and Welfare through the Office of the Public Guardian to make decisions on their behalf?
      • If yes, decisions must be made accordingly. If not, we must make decisions in their best interests.
  • After Death
    • Organ donation legislation differs throughout the UK:
      • The legislation (December 2015) for Wales is ‘deemed consent’.  This means that if you haven’t registered an organ and tissue donation decision, you will be considered to have no objection to becoming a donor.
      • In England (May 2020) there is an opt-out system.All adults in England are now considered to have agreed to be an organ donor when they die unless they have recorded a decision not to donate or are in one of the excluded groups
      • The legislation for Scotland is ‘deemed authorisation’. This means that if you have not confirmed whether you want to be a donor or not, you will be considered to be willing to donate your organs and tissue when you die.
      • The current legislation for Northern Ireland is to opt in to organ and tissue donation. In 2020 the Department of Health in Northern Ireland announced a consultation on proposed changes to an opt out system of consent for organ donation.
      • For any patient for whom a decision has been made to withdraw life-sustaining treatment, a discussion should be held with the Specialist Nurse for Organ Donation (SNOD)
      • referral mechanisms to the Coroner or Procurator Fiscal and the preservation of evidence in forensic cases.

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