End of life discussions

1. Urgent End of Life Care
Discussions
Dr Katherine Buxton
Medical End of Life Care Lead Imperial
Consultant in Palliative Medicine

2. Contents
• National Context
• 5 priorities for care of dying patient

3. National Context

5. 5 PRIORITIES FOR CARE OF THE
DYING PATIENT
One chance to get it right: Neuberger Report: 2014
NICE guidance for care of dying adults in the last days of life: 2015

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

7. Diagnosing Dying
• Can be a challenge and advise should be sought from
specialists in difficult cases
• Information that can help includes:
– Medical history & relevant diagnoses
– The patients physiological, psychological, social and spiritual
needs
– Recent changes in communication, deteriorating PS or mobility
and other clinical functions
– Symptoms such as increasing fatigue or decreasing appetite
– Changes such as mottled skin, cheyne stoking respiration,
deteriorating level of consciousness or noisy respiratory
breathing
– Patients wishes and goals
– The views of those important to the person about future care

8. Priority Two
Sensitive communication takes place between
staff and the person who is dying and those
important to them

9. Communication of Dying
• Does the dying patient have capacity?
• Previously expressed wishes? ADRT? LPA? CMC?
• Do they wish those important to them to be involved in
conversations?
• Patients understanding of where they are in illness and
gauge level of information they wish regarding
prognosis
• Share accurate information with patient and family
regarding prognosis, explaining uncertainty where
possible and how this will be managed
• Clarify patient wishes in dying phase if able and willing
to hold conversation

10. Priority Three
The dying person, and those identified as being
important to them, are involved in decisions
about treatment and care

11. Shared Decision-making
• Establish level to which patient wishes to be
involved in developing care plan
• Ensure honesty and transparency in discussion
• Consider advance decisions, ADRT, LPA and other
expressed preferences/wishes alongside cultural,
religious, social and spiritual preferences
• Ensure a key contact is identified to be
responsible for reviewing and updating care plan
and communicating with patient and family

12. Priority Four
The people important to the dying person are
listened to and their needs are respected

13. Priority Five
Care is tailored to the individual and delivered
with compassion – with an individual care plan
in place

14. Development of Plan of Care
• Key areas to cover include:
– Agreement on ceilings of care, CPR status
– Preferred place of care/death
– Resources necessary to achieve this e.g. funding, POC,
equipment, trained nurses, specialist services, GP,
oxygen, medication & prescriptions
– Preferences for symptom management
– Needs for care after death, if any specified
– Sharing of care plan across the settings and with
emergency services in case unexpected situation
occurs e.g. via CMC

15. Patient name: Ward: Discharge Date:
Patient number: Consultant:
SPC Lead: Discharge team lead:
Tick Comment
DN referral Name
Contact
First visit – date : time
Equipment in place (EOLC urgent request)
Eg. Hospital bed commode/Bed pan / urinal
bottle/ catheter Syringe pump
GP informed Update on medical condition discussions and
plan
First visit – date : time
GP Home visit requested
GP Community prescription prn and csci
requested
GP requested to complete Community DNAR
Community SPC
referral
Name
Contact
First visit – date : Time
Does patient need
oxygen ?
Y / N
If yes O2 ordered
If yes O2 in place
Anticipatory
medication
prescribed and
ordered on EDC
Pain
Agitation / restlessness
Nausea / vomiting
Secretions
Breathlessness
Water for injection
Consider oral too eg. Opioid and lorazepam
Patient not on
syringe driver to
control symptoms in
hospital
Consider prescription of anticipatory syringe
pump
Patient on syringe
driver to control
symptoms in hospital
Plan for discharge with ICHNT syringe pump
(document plan for return of syringe pump)
Plan for discharge without ICHNT syringe pump
(document plan for managing symptoms)
CMC record
completed prior to
discharge
Date completed
Print out given to patient / relatives
EDC EDC completed medical team
SPC entry on EDC
Copy sent to community SPC
Fast track care
funding agreed
Agreed package
Contact eg. HatH
Start date and time
Transport booked Book lone transport EOLC priority
stretcher
Date : time
DNAR for transport
Carer aware what to do when patient dies at
home
Patient / Carer given contact details for in
hours and OOH DN and community SPC
Imperial Specialist Palliative Care Discharge Checklist
Ward nurse role Medical team role Discharge team role SPC team role

16. THANK YOU