End of Life Care PlanningRita Gallagher

Newpark Care Centre

21-03-2014

End of Life Care planning

The end of life of phase ‘applies to people with a variety conditions and involves a longer time period than the days or weeks immediately before death.( NCAOP 2008)

End of life care planning

‘care that helps all those with advanced, progressive, incurable illness to live as well as possible until they die’

• e.g. those with Dementia, Recurrent repeat infections, exacerbation of chronic illness

• The NHS (2007)defines EOLC as

End of life care planning

• This enables supportive, palliative care needs of both the resident and their family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms plus the provision of psychological, social and practical support

End of life care planning

• Physician Orders for Life-Sustaining Treatment• POLST

End of life care planning

• Nursing Homes Nursing Projects • In association with Dr S. Kennelly -Inappropriate presentations at A&E -EOLC

Trial of Regina Mc Quillan, initial work on EOLC and POLST type document, we adapted it slightly before we adopted it.

  Section D Check One Box Only in Each Column

 MEDICALLY ADMINSTERED FLUIDS AND NUTRITION: Oral fluids and nutrition must be offered if medically feasible.  No iv fluids No feeding tube S/c fluids for a defined trial period feeding tube for a defined trial period s/c fluids long- term if indicated Feeding tube long- termOther instructions (e.g. alternative hand-feeding care plan in place if appropriate):___________________________________________________________________________________________________________________ 

  Section E

 ANTICIPATORY PRESCRIBING: Please be aware of special circumstances which might require different drugs- use clinical judgement Oral medications 1) Paracetamol 1g 6 hourly P0/PR PRN for signs of pain, discomfort & pyrexia 2) Alprazolam 0.125mg PO 4 hourly PRN for signs of anxiety, dyspnoea 3) Oramorph 2mg PO 4 hourly PRN for signs of pain, dyspnoea Subcutaneous medications ( where patients no longer able to take oral medications ) 4) Morphine sulphate 2.5mg s/c 4 hourly PRN for signs of pain, dyspnoea 5) Midazolam 2.5mg s/c 4 hourly PRN for signs of agitation, restlessness 6) Hyoscine Butylbromide 20mg s/c 4 hourly PRN for signs of problematic upper airway secretions. 

**Medications to be prescribed at discretion of general practitioner. Consider Diclofenac 100mg pr where no contraindications to same

  Medications  Medications rationalised where possible to reduce tablet burden and where no longer appropriate given patient’s condition and prognosis. 

  Section F

 Nursing and Support services ( to be organised by hospital medical + nursing team where patient is being discharged from hospital or if patient being transferred from nursing home to hospital)  Liaise with hospital palliative care team Liaise with community intervention team as appropriate Date of discharge confirmed with Patient/family and nursing home Confirmation that medications available in nursing home 24 hours prior to transfer Appropriate transport arranged and confirmed, DNR letter for ambulance crew Fully comprehensive nursing discharge letter 

  Section G

 Specialist Palliative Care InputTo be completed by specialist palliative care only  Patient seen in Hospital Patient for Community Palliative Care from Location __________________________________________ Patient not for Community Palliative care; Medical Officer can contact appropriate Community Palliative Care service for advice 

   

 Date: ___________________________ Review Date (3 months) ____________

 Signature: _____________________________________(GP/ Consultant) Signature: ________________________________(Director Of Nursing)

Name: _______________________________

Address: _____________________________

Date of Birth: ________________________

M.R.N Number: ______________________ (if in hospital)

These are guidelines for the medical/ nursing team based on the patient’s medical condition and wishes. A COPY SHOULD BE KEPT IN THE PATIENT’ S MEDI CAL

RECORDS IN THE HOSPITAL AND IN THE NURSING HOME and should accompany patient when transferred. This document should be discussed with patient/family, nursing home manager and GP prior to transfer if patient is being discharged from hospital. THIS IS NOT A TICK BOX EXERCISE

NEWPARK CARE CENTRE / GUIDELINES FOR PATIENTS RESIDENT IN /RETURNING TO NURSING HOME FOR SUPPORTIVE- COMFORT CARE

Name of GP/ Medical Officer with whom

this plan discussed

Name of Director of Nursing / Clinical Nurse Manager with whom this plan

disc ussed

Name/s of family members with whom this plan discussed

The basis for these orders is: o Patient’s preferences ¨ Patient’s best interest

Section A Check One Box

Only

CARDIOPULMONARY RESUSCITATION (CPR): Person has no pulse and is not breathing.

¨ Attempt Resuscitate (CPR) o Do Not Attempt Resuscitation (no CPR)

If DNR, letter for ambulance crew When not in cardiopulmonary arrest, follow B, C and D

Section B Check One Box

Only

MEDICAL INTERVENTIONS:

Comfort measures Treat with dignity and respect Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Refer

to Section C re antibiotic care plan. Use oxygen, suction and manual treatment o f airway obstruction as needed for comfort. Refer to Section D for nutrition and fluid plan. Do not transfer to hospital for life – sustaining

treatment. Transfer only if comfort needs cannot be met in current location. o Limited Additional Interventions Includes care described above. Use medical treatment. Refer to Section C

re antibiotic care plan. Refer to Section D for nutrition and fluid plan. Do not use intubation, advanced airway interventions, or mechanical ventilation.

Transfer to hospital if indicated. Avoid intensive care ¨ Full Treatment Includes care above. Use intubation, advanced airway interventions, mechanical ventilation,

and cardioversion as indicated. Transfer to hospital is indicated. Include intensive care.

Other instruction s:_______________________________________________

End of life care planning discussions in that regard can be complex , lengthy and make take more than 1 conversation !

Guidelines for use:

• ALWAYS try to ascertain the views of resident• Decisions re personal health rest primarily with the resident AND

medical team ONLY• Family collaboration is important• GP involvement essential

COMMUNICATION IS KEY

Important that these discussion around EOLC are made at senior staff level-

• Residents MUST be made aware that there are occasions where transfer to hospital would be in their best interests e.g fracture

• The EOLC document is photocopied and travels with the resident• Anticipatory medications are written up by GP• Document

• Review usually 3/12

And you might think its all over/Done Be prepared! you may have to revisit• WHY ?• LISTENING TO RESIDENT-• RATIONALE FOR DISCUSSION • APPROPRIATE TREATMENTS• COMPLEX CONVERSATIONS • CLEAR COMMUNICATION BETWEEN EVERYONE INVOLVED• SUPPORT

End of life care planning

• This document is not stand alone and MUST be used in conjunction with care planning.

• Care plans should include details of residents wishes on EOLC• Wishes and expectations if they become unwell • Views on transfers to hospital• All staff must be aware of their wishes• Family must be aware • COMMNICATION IS KEY• Good robust documentation is important

End of life care planning

• In 2012 there were 17 deaths in my facility• 15 had EOLC plans in place • Those 15 were cared for in the nursing home and passed away there • 1 was a respite who became unwell and died in nursing home • 1 suffered a trauma and was transferred to hospital where they passed away • This process takes a lot of time , good rapport with GP, knowledge of the resident

and their condition, getting to know resident and family ,family dynamics and being confident in the care your facility can deliver.

End of life care planning

• Of interest perhaps adapted from Australian aged care (Queensland Government)• Adapted from Residential Aged Care end of Life Care Pathway• Comfort care plan docs-Instructions for completing Pathway• Very useful for monitoring care when a resident is very ill • They assist with decision making process• Ensure there is a clear rationale for administering medication (anticipatory)• Is excellent at tracking care for nurses -at change of shifts- for other allied health

care staff –gp, and the likes of me DON

Resident Name:_______________________

DOB:__________________

Room:_________________

1 Record an entry against each item, as appropriate2 Minimum documentation is 4 hourly, though3 Psychosocial issues may only need assessment twice weekly4 Further Actions (F/A) taken, other than Routine Care (R/C) To be recorded on the 'Further Care Action Sheet'(Sec 3 Part C)5 A new chart to be commenced each day

Score each box: A = assessed and no action required F/A = further action required R/C = routine care N/A = not applicable

Date: 02:00 04:00 06:00 08:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 24.00

SYMPTOM MANAGEMENT

Agitation

Nausea / Vomiting

Respiratory difficulties

Rattly respirations

Pain

Subcutaneous cannula check

Subcutaneous infusion check

ROUTINE COMFORT MEASURES

Comfortable positioning

Mouth care - clean and moist

Eye Care - clean and moist

Skin care

Micturition - dry and comfortable

Bowel Care

PSYCHOSOCIAL

Procedures explainedInformation regarding changesprovided

Any new concerns responded toSpiritual, religious, cultural needs/rituals identified and facilitated

Nurse's Signature

Section 3: Part B - Comfort Care Chart

NEWPARK CARE CENTRE

1 Please record Further Actions (F/A) taken on this sheet2 If your facility uses medication stickers to record symptom management, they can be applied to this page

Date Time What Occurred Action Taken Signature Time Yes NoIf 'NO' what further action was taken? Signature

Was action effective?

Newpark Care Centre End Of Life Care Pathway

Comfort Care Document

End of life care planning

• Thank you

• Any Questions ?