Coventry and Warwickshire Unified Holistic Assessment and ...

Coventry and Warwickshire Unified

Holistic Assessment and Individual Plan of Care

for the Dying Person Final version December 2017

Date:

Time:

Place of care:

Person’s Name:

NHS Number:

DOB:

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Coventry and Warwickshire unified Holistic Assessment and Individual Plan of Care for the Dying Person v7 FINAL 05.12.17

Coventry and Warwickshire Unified

Holistic Assessment and Individual Plan of Care

for the Dying Person This is a multi-professional assessment and individualised care planning tool involving the nursing and medical team. This assessment and care plan should be reviewed regularly and include clear communication with the multi-professional team, the dying person and those important to them. This care plan is individualised for the person and those important to them. Please seek advice if you need support to complete this document.

It is recommended that once this document is started all multi-professional evaluations and daily records of care are recorded in this document only and that the usual / previous clinical record is no longer used; it is recognised that in primary care the electronic GP clinical record continues.

Whenever the person’s condition changes, reassess and document your reassessment and revised care plan.

If the person stabilises and is no longer felt to be dying then this individual plan of care should be discontinued.

This document has been developed to support the Five Priorities of Care for the Dying Person identified in “One Chance to Get it Right” June 2014 by the Leadership Alliance for the Care of Dying People. These are:

The possibility that a person may die within the coming days and hours is recognised and communicated clearly; decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly.

Sensitive communication takes place between staff and the dying person, and those identified as important to them.

The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.

The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.

An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, co-ordinated and delivered with compassion.

If further support or advice is needed please contact the relevant specialist palliative care team: (for clinical staff use only): **EACH ORGANISATION TO REPLACE WITH OWN CONTACT DETAILS** Locality/ Organisation: Hours of operation:

Locality/ Organisation: Hours of operation:




Out of Hours

Telephone 0123456789





Your organisation’s 7 day service Telephone 0123456789 Myton Hospice Clinical Telephone advice line via Telephone 01926 492518

Organisation’s Chaplain/Faith representatives: Information for Locality/ Organisation: Hours of operation:





Initial Assessment of the Dying Person

Sections highlighted in blue should be completed:-

in the hospital and hospice settings by the medical team in the community setting by the responsible nurse in discussion with the person’s GP

Print Name Sign, Date, Time for each section that you complete

1.0 DIAGNOSIS: Comorbidities:

1.1 GP/Consultant responsible for the person? Name………………………………………………………………………………………………………………………………………… For the patient in hospital or hospice: the Consultant/ Registrar (circle) – Name:……………………………………………… or at home: the GP – Name:…………………………………………………………………………………………………………… agrees that the person is dying and is aware that this individual plan of care is now in place. Date this conversation took place……………………………………………………………………………………………….

1.2 There are no reversible causes for the person’s deterioration

(e.g. infection, hyperkalaemia, renal failure, change in medications, hypoxia)

Or, the person has declined further investigation/ potentially life prolonging treatment after discussion about the benefits, burdens and risks

Or, there is potentially life prolonging treatment, but a decision has been made that further investigation/ potentially life prolonging treatment would not be in the person’s Best Interests, (refer to section 1.10)

1.3

The person is recognised by the multi-professional team as dying. Prognosis is likely to be hours to days. Please document why this decision has been reached?

1.4 The recognition that the person is dying has been discussed with

the person (if they are able to communicate and wish to know)

the family or significant others Please document an overview of the discussion that took place, detailing names of those involved in the discussion or reasons why this did not occur (state reason why if the dying person was not able to participate in this discussion). Include an explanation of how and when the person might die and a basis for this judgement, acknowledging uncertainty.




Initial Assessment of the Dying Person continued Sections highlighted in blue should be completed:-

in the hospital and hospice settings by the medical team

in the community setting by the responsible nurse in discussion with the person’s GP


1.5 Date the DNACPR decision was made?

1.6 If the person has an Implantable Cardioverter Defibrillator (ICD) Has this been deactivated? Yes/ No/ Not Applicable If the person has an Implantable Cardioverter- Defibrillator (ICD) which has not yet been deactivated, consider whether deactivation is appropriate; refer to the GP/ Consultant in charge of the person's care if required. As for all care planning decisions, involve the person, or make a Best Interests' Decision in line with the Mental Capacity Act and associated guidance if the person does not have the capacity to be involved fully in the decision. Deactivation of the defibrillator mode of an ICD does not deactivate the pacemaker mode and in itself does not end a person's life, but will remove the risk of uncomfortable shocks around the time when the person dies naturally. If the person is in hospital, community or hospice, aim to call the hospital cardio-respiratory department within working hours to arrange deactivation of the ICD. In the urgent out of hours situation; - for persons in hospital, contact the Coronary Care Unit (CCU), or, - for persons in the community, contact Myton Hospice to obtain a magnet to deactivate the ICD.

1.7

What are the person’s wishes for when they are dying (in the last hours or days of life)? Please refer to any Advance Care Plan/ Advance Decision to Refuse Treatment and ensure that it remains valid.

Consider spiritual, religious, psychological, social and cultural needs/ preferences; the Family’s understanding of these wishes. Have you offered support from a Chaplain/Faith Representative? Yes/ No Name and contact number:

1.8 Where is the person’s preferred place of death at this time?

1.9 Has the person made a request to donate suitable tissue after death? Yes/ No If yes, are the family aware of what action might be needed after death? Yes/ No Comment: Transplant co-ordinator contact number (24/7): 07659137821

1.10 Mental Capacity

The law states that you should assume that all people have mental capacity to make their own decisions unless you have doubt. Do you have any doubt whether this person has the capacity to consent? YES/ NO If yes, then complete a Mental Capacity Assessment for EACH decision that the person needs to make and make a decision in the person’s Best Interests if appropriate according to your own organisation’s policy and procedure

1.11 If the person has a dementia diagnosis do they have a personal information document? (e.g. Alzheimer’s Society tool “This is me” document) Yes/ No/ Not applicable. If yes, please refer to this to plan and provide personalised care.

1.12 If the person has a Learning Disability do they have a ‘Hospital Passport’? Yes/ No/ Not applicable. If yes, please refer to this to plan and provide personalised care.

1.13 Are there any difficulties related to Hearing/ Vision/ Communication? If so please document below

Is an interpreter needed?




Family/ Carer: Communication and Support Print Name Sign, Date, Time for each section that you complete

2.0 Family/ carer contacts:

First contact Name:

Relationship to person:

Contact number:

Alternative number:

Willing to be contacted at any time? Yes/ No If not please detail

Second contact Name:

Relationship to person:

Contact number:

Alternative number:

Willing to be contacted at any time? Yes/ No If not please detail

2.1 Inpatient carers communication:

Give advice on: Refreshments/ Toilet Facilities Open visiting Carers’ facilities Discuss car parking Information leaflet about caring for someone who is dying

Community carers communication: Give advice on Contact numbers for Out of Hours support and assistance Any specific needs to be considered? Information leaflet about caring for someone who is dying

2.2 Is there anyone the person doesn’t want information shared with?

2.3 What are the concerns and worries of family/carers present at this time? (Consider their spiritual, psychological and social concerns)

2.4 Do they wish to be involved in the general care of the person? Yes/ No Name(s) of carer/s:

2.5 Have you offered support from a Chaplain/Faith Representative for family/ carers? Yes/ No Name and contact number:

2.6 Maintaining dignity after the person has died: Do the family/ carers know who to call when the person dies at home? Yes/ No/ N/A Has information been provided to family re: what to do when their relative dies Yes/ No Consider asking whether a funeral director has been identified? Yes/ No If a funeral director has been identified - contact details: Please ensure that the Verification of Death Policy has been followed

2.7 Confirm any specific Spiritual/ Cultural/ Religious needs after the person has died: Consider asking the relative/carer if they wish to participate in care after death.




Multi-professional Actions Sections highlighted in blue should be completed:-

in the hospital and hospice settings by the medical team in the community setting by the responsible nurse in discussion with the person’s GP


3.0 Review the need for monitoring vital signs, clinical investigations and AHP interventions eg: mobilising and exercises. Comment:

3.1 Review and discontinue inappropriate or unnecessary medication Ensure essential medication is prescribed via appropriate route (e.g. converted to a syringe driver) N.B. essential medication for control of seizures and Parkinson’s Disease

3.2 Prescribe anticipatory medications for common symptoms in the last days of life via the appropriate route Refer to the general principles and algorithms for Prescribing for the Dying Person: THINK: pain, nausea/vomiting, agitation/restlessness, respiratory tract secretions, breathlessness, dry mouth. Explain the medication(s) and possible side effects to the person and/or family

3.3 Is this person receiving clinically assisted hydration or nutrition? Yes / No Consider whether appropriate to continue, stop or commence hydration e.g. SC/ IV fluids nutrition e.g. NG/ PEG/ TPN. Please detail decision and rationale.

3.4 If being discharged home, ensure – CHC/Fast Track

Equipment in place

Medication directives completed by prescriber

District Nurse and GP informed

Other: …………………………………………………………………………………………………………………………………

3.5 Contact Out of hour’s service to inform them that this individual plan of care for the dying person is in place for patients in the community. Please detail contact/s made.




Initial Holistic Assessment

Individualised care plan (See page 9 for examples of things to consider)


Physical Please detail symptom severity below: Please detail the care plan below for each applicable symptom:

Pain/ Discomfort

Agitation/ Restlessness

Nausea/ Vomiting

Excessive Respiratory Secretions

Breathlessness

Hydration and Nutrition

Dry mouth or coated tongue

Urinary problems

Bowel problems

Skin integrity issues




Initial Holistic Assessment Please document the

Psycho-social assessments and Communication section below

Individualised care plan Please detail the care plan for each section below

(See page 9 for examples of things to consider)


Social

Document current social situation Detail any concerns

Spiritual

Detail any spiritual needs/concerns

Psychological

Are they worried, anxious, distressed or frightened?

Physical Closeness Consider those important to the person and how to enable the person's ‘sense of self’

Other

This assessment and care plan has been fully discussed and agreed with:

person (if they are able to communicate and wish to know) and

family / carer / significant others (in accordance with person’s prior wishes) Please detail names and summarise discussions that took place

Refer to the general principles and algorithms for Prescribing for the Dying Person.

Seek specialist palliative care advice if symptoms do not improve or undesirable side effects




Things to consider when caring for the dying Pain/ Discomfort

Assess the person’s level of pain regularly and frequently

Consider non pharmacological and pharmacological management of pain

If pain is identified manage it promptly and effectively

Treat any reversible causes of pain, such as urinary retention or oral thrush.

Consider best route of medication administration

Match the medicine to the severity of pain

Agitation/ Restlessness

Explore possible causes of anxiety, agitation, and restlessness with the dying person and those important to them

Be aware that agitation in isolation is sometimes associated with unrelieved symptoms or bodily needs for example, unrelieved pain or full bladder or rectum.

Ensure environment is calm, adequate lighting, quiet and familiar personal objects/photos

Discuss if possible whether the presence of close friend/relative can help reassure the person

Liaise with medical team and discuss administration of appropriate medication and review effectiveness.

Nausea/ Vomiting

Identify how often, how long, precipitating and relieving factors

Identify any possible causes i.e. certain medicines, recent chemotherapy, psychological causes, bowel obstruction, smell of food or constipation; Rectify if possible

Provide / ensure vomit bowl and tissues near

Privacy and dignity at all times

Discuss the options of treating nausea and vomiting with the dying person and those important to them

Liaise with medical team regarding type of anti-emetic, route to be given, effectiveness of treatment

Excessive Respiratory Secretions

Assess the likely cause of noisy respiratory secretions

Establish whether they are having an impact on the person or those important to them

Reassure them that, although the noise can be distressing, ease their distress by explaining that the semiconscious/unconscious person will generally not be distressed by the rattle, also consider non pharmacological measures to manage noisy respiratory secretions to reduce any distress

Consider a trial of medicine to treat noisy or excessive secretions if they are causing distress

Monitor the effect of any medicines given including unwanted side effects such as dry mouth, urinary retention, delirium and agitation; Consider changing or stopping medicines if unacceptable side effects persist

Breathlessness

Identify and treat any possible causes of breathlessness such as pulmonary oedema or pleural effusion.

Ensure person is nursed in an upright position if this is most comfortable

Use fan therapy if tolerated

Spend time listening to the person and family, reassure that they are safe and breathlessness can be managed.

Hydration and Nutrition including Dry mouth or coated tongue

Clear communication at this time is essential

Support the person to drink if they wish to and are able to

Mouth care should be delivered as frequently as required; Assess for oral thrush and treat accordingly

Does the patient feel thirsty? Are there any signs of thirst?

Have hydration measures been considered? Discuss benefits and potential harm

Consider therapeutic trial of clinically assisted hydration where appropriate

Urinary Problems and Bowel Problems

Review for any urinary problems or symptoms; Consider whether a urinary catheter may be beneficial

Establish person’s normal bowel patter; Monitor and document bowel action

Assess factors which may be contributing to the constipation; Promote privacy and dignity

Administer and review effectiveness of laxatives given

Promote adequate fluids as tolerated

Liaise with medical team regarding any further action and review medication

Skin integrity issues

Comfort needs around skin integrity will differ from person to person and care should be planned on an individual basis focusing primarily on maintaining comfort and reducing distress

Undertake discussions about skin changes, skin breakdown and pressure ulcers with the person and those important to them

Complete wound/ pressure ulcer assessment

Seek advice from specialists re products/ aids to be used as appropriate

Plan/ schedule repositioning/ dressing changes according to individual needs; Is analgesia required prior to repositioning?

Has this information been relayed to care agencies if involved?

Physical Closeness

Be sensitive and respectful in supporting couples to allow them to express their deep thoughts and feelings

Consider giving permission for touch

Ensure dying person and those important to them have privacy to share time together without interruption

Consider who and how personal care is given based on the person's wishes Consider ways of touch that a partner may wish to be involved in e.g. applying body lotion

Communication • Consider the person’s first language; ensure that appropriate translator services are utilised at key points as required

• Ensure ongoing sensitive communication regarding the plan of care • Allow opportunities for on-going questions or concerns to be addressed • Ensure communication aids are being used if appropriate




Whenever the person’s condition changes, reassess and document your reassessment and revised care plan.

If the person stabilises and is no longer felt to be dying then

this individual plan of care should be discontinued.

The mnemonic STARS and COMFORTS may be utilised as a prompt to assist

ongoing documentation if staff find this helpful.

S Sickness

T Troublesome breathing

A Agitation and Anxiety

R Relief of Pain

S Secretions

C Catheter / Elimination

O Oral care / Eye care

M Mattress (highest specification)

F Feelings – psychological, spiritual, religious wellbeing of patients and carers

O Offer fluid / food by mouth as tolerated

R Respect individual needs – personal hygiene: e.g. hair, shaving, own night clothes

T Tubes, lines, drains, syringe drivers

S Skin assessment / integrity

As part of your organisation’s own operational policy you may use the

mnemonic to guide your clinical re-assessment. The guidance is at least once daily in all clinical settings and

a minimum of 4 hourly re-assessment in the Acute Trusts.




Date & Time

Care Given and ongoing multi-professional notes Please document care given and evaluate its effectiveness for any symptoms and comfort measures on each shift or as clinically indicated.

Print Name and Sign for each entry



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