Priorities for Care of the Dying Person - neleolcare.org

Palliative & End of Life Care Services N E Lincs

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Care in the Last Days of Life

NE Lincolnshire

Macmillan Palliative Care Team

2018

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One Chance to Get it Right (2014)


Developed by Leadership Alliance for the Care of the Dying People. This replaces the LCP, no longer use this from July 2014 (no longer on EOL website). The Priorities for Care are that, when it is thought that a person may die within the next few days or hours.


Priorities for Care of the Dying Person

1. This possibility is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.

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



3. 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.

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



5. 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.


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Recognising the Dying Patient


Challenges

• Skill and knowledge to identify the onset of the dying,

• Lack of agreement between MDT and /or family

• Dying phase not always clear in chronic conditions i.e. heart failure

• Is the cause of the decline reversible?

• Fear of misdiagnosing dying


Why Is It Important?

• Makes it possible for all involved to acknowledge death is imminent and is a crucial time of adjustment,

• Fosters open communication between family, carers and MDT

• Allows for care aims and interventions to change – allows for initiation of a care plan for dying.


Group work

• How many signs and symptoms can you name to recognise a person is dying?


Signs and Symptoms

• Day by day deterioration or faster

• Patient expresses a realisation that they are dying

• Reduced cognition, drowsy or comatose

• Bed-bound

• Taking little or no food or fluid

• Difficulty with oral medication


Signs and Symptoms

• Altered breathing pattern

• Peripherally cyanosed and cold

• Retained bronchial secretion

• Reduced urine output

• Cessation of bowel function


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Communication Skills In Last Days Of Life


Why is it Important to Communicate

• Reduces patient/family anxiety

• Assists patients in making their own choices

• Reduces patients sense of isolation

• Helps to increase patient satisfaction and outcomes with the care received and reduces complaints

• Increases job satisfaction


Ways of communicating- Who? When? Where?

• Verbal communication= words spoken,

• Non verbal communication= actions, facial expression, touch, silence, gestures, personal space, eye contact, posture.

• Listening


Barriers of Communication for staff

FEAR of • Upsetting the patient • Saying the wrong thing and getting into trouble • Causing more harm than good • Unleashing strong emotions • Being asked uncomfortable/ unanswerable questions • Patients emotional reactions • Others will perceive you as lazy for spending time

talking with patients. • You will get into a situation that will be difficult and

you will not receive the support from senior staff


Barriers of Communication for Patients

• Feeling unable to verbally express feelings • Fear of admitting they can’t cope • Afraid of the answers they may get • Afraid of breaking down, crying or loosing

control • The staff are too busy to listen/talk • Feeling that nobody is interested in them or

their worries. • Attempts to protect others from their feelings/

devastation


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Skills to Utilise

• Listening • Silence • Acknowledgement • Encouragement • Picking up cues • Reflection • Open questioning • Clarification • Empathy • Confront / challenge • Information giving


Skills to Utilise

• But most important

HONESTY


How to be a Good Listener

We might think that talking and listening goes like this:

You Speak I Listen

You Listen I Speak


Truth is…..

You speak

I listen

• Evaluate

• Listen

• Plan

• Listen

• Rehearse

• Speak at the first opportunity I find to stop you


https://www.nhs.uk/Video/Pages/you-only-die-once-kates-story.aspx


What happens when it goes wrong?

Results in patients and relatives being:

• Angry

• Sad

• Uninformed

• Confused

As a result they often complain.


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Communication Skills

• Good communication of a dying persons prognosis improves their end of life care and the bereavement experience of those important to them.

• Patient and relatives often choose who they wish to discuss issues with

• Verbal and non-verbal communication occurs every encounter between health professional and patient/relative

• Good face to face communication can improve outcomes for patients/relatives

• Improves ability to participate in the decision making process • Patient/carers frequently report that the communication skills

of health and social care professionals are poor. (N.I.C.E. 2004/2015)


Communication Skills

Some Health and care professional are uncomfortable discussing how long someone has left to live and sometimes do not have the skills and confidence to give difficult news or talk about the dying process. Adequate training and continued support is important to help health and care professionals to communicate sensitively and effectively

(N.I.C.E. 2015)


Communication Exercise


Care Planning at the End of Life.


Who Plans Care?

• District nurses • Doctors • Trained nurses • Senior Carers • Specialist Nurses • Macmillan Nurses • Out of hours • Patient • Family • Allied Health Professionals


Tools

• My Future Care Plan

• Holistic Needs Assessment

• Green Handover Form

• Aid memoire for EOL care

• EOL care website

• Bereavement booklet

• DNACPR policy

• Macmillan team / DN teams /Specialist Nurses/Hospice / Hospital


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DNACPR

• What?

• Who?

• When?

• How?

• Why?


Recognising and Managing Symptoms?


What are the Challenges for you?


Anticipatory Medication

• Pain – Diamorphine, Oramorph

• Nausea and vomiting – Cyclizine, Haloperidol

• Agitation –Midazolam

• Delirium – Haloperidol

• Respiratory secretions – Glycopyrronium

• Other drugs may be used when deemed medically appropriate


Pain

• A highly unpleasant physical sensation caused by illness or injury, mental suffering or distress.

• Total pain is a personal experience with physical, psychological, social and spiritual dimensions.


Pain. Non Drug Treatment

• Position • Heat or cold • Reassurance • Distraction • Complementary therapy / Massage • Reverse the reversible • Environmental adaptions • Pet therapy • Physio


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Nausea and vomiting

• Nausea-an unpleasant feeling of the need to vomit, often accompanied by autonomic symptoms eg pallor, cold sweat, salivation, tachycardia, diarrhoea.

• Vomiting- the forceful expulsion of gastric contents through the mouth.


Nausea and Vomiting. Non drug Treatment

• Remove stimuli ie smells

• Calm environment

• Nurse in upright position

• Small regular meals

• Hypnosis

• Acupuncture

• Behavioural therapy

• Reverse underlying cause


Agitation

• A state of anxiety or nervous excitement.


Agitation. Non Drug Treatment.

• Nurse in calm environment

• Reduce stimuli

• Increase / decrease visitors

• Consider cause eg bladder, bowels, position, temperature

• Reassure


Delirium

‘Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.

NICE 2010


Delirium None Drug treatment

• Keep calm and avoid confrontation

• Nurse in a calm environment

• Respond to the patient’s comments

• Clarify perceptions & validate those which are accurate

• Explain what is happening & why

• Request assessment from qualified/ medical staff.


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Respiratory Secretions

• A term used to describe noisy rattling breathing occurring in about 50% of patients at end of life.

• Caused by fluid pooling in the hypo pharynx.


Respiratory Secretions Non Drug Treatment.

• Reposition patient –semi prone

• Suctioning

• Physio

• Reassure family


Important things to consider

• Bowels • Bladder • Position • Mouth care • Pain • Environment • Fear • Isolation • Temperature • Family and friends


Syringe Drivers

• What is it?

• Why would it be used?

• When would it be used?


Syringe Driver: Mckinley T34 Pump

Inflamed red skin and cannula


Compassionate Care


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Compassion in Practice (2012)

• This strategy sets out a shared purpose for nurses, midwives and care staff to deliver high quality, compassionate care, and to achieve excellent health and wellbeing outcomes.

• This document set out the 6Cs


6 Cs

• Care

• Compassion

• Competence

• Communication

• Courage

• Commitment


What is Compassion?

• Compassion, or caring can be viewed as ‘nursing’s most precious asset’ (Schantz, 2007)

• A fundamental element of nursing care and seen as one of the strengths of the profession (Dietze and Orb, 2000).

• The Politicians notion according to Alan Johnson (former Health Secretary) features smiles and empathetic care (Carvel, 2008)


What is Compassion

• One of the difficulties in considering the issue of compassion’ is that everyone, nurses patients and politicians will have their own personal subjective definitions.

• Personal definitions fit in with our own view of the world.


Think About What the Term Compassion Means to You?

• Reflect on a time when someone interacted with you in a compassionate way.

• What did they do?

• How did this feel?


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Compassion

• Is a value recognised by nurses, midwives, care staff and the public. It is seen as a force within you as well as an action you can preform.

• It occurs between 2 people and is fixed in a particular time and place. In can be represented in many ways: a word, a smile, an act of kindness or by listening to another person.

• It is an experience in which one person recognises and responds to the suffering of another by giving emotional energy. (Compassion in Practice – one year on 2013)


Compassion In Practice –One year on 2013

• ‘compassion can be as simple as a hand on a shoulder’ (Care Maker)

• ‘Propping up the pillows of a patient who was uncomfortable and making sure their table and drink was close so they could reach it’ (Care Maker)

• ‘Compassion is …imagination…creativity and empathy …and having a degree of thought of what can I do, how can I make this better? (Midwife)


“ we’re designed to respond to the care and kindness of others. When we’re distressed,

kindness helps; if we’re facing tragedies such as the loss of a loved one, the kindness of others helps; if we’re having to face our own death,

then feeling loved and wanted is important to our ability to face it”

Paul Gilbert. The Compassionate mind.


Compassion should be an integral part of everyday nursing care, with the role of the

health care professional to “…respond with humanity and kindness to each

person’s pain, distress, anxiety or need. We search for the things we can do, however small,

to give comfort and relieve suffering”

NHS Institute for innovation & improvement 2013.


Unique Person


A quote from Bob Wright; “…that the person was more valued than the person’s role. It is our own humanity that is experienced by relatives in those situations. They remember many personal details about us…..

If your role, experience or expertise, appears to have little to offer, or if you feel ineffective or impotent, do not be afraid to fall back on your own personal skills, your own humanity.

People remember with warmth and are grateful for the person they meet on that awful day” Bob Wright.


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Self Compassion

• Self-compassion involves acting the same way towards yourself when you are having a difficult time, fail, or notice something you don’t like about yourself. Instead of just ignoring your pain with a “stiff upper lip” mentality, you stop to tell yourself “this is really difficult right now,” how can I comfort and care for myself in this moment?


Self Compassion

• How do you look after yourself?

• Are you supported at work?

• Who supports you?

• Supervision / reflection / team meetings


Self Compassion

Being kind to yourself- ten commandments. 1. Thou shalt not be perfect, or even try to be. 2. Thou shalt not try to be all things to all people. 3. Thou shalt sometimes leave things undone that ought to be done. 4. Thou shalt not spread thyself too thinly. 5. Thou shalt learn to say ‘no’. 6. Thou shalt schedule time for thyself and for thy supportive network. 7. Thou shalt switch off and do nothing regularly. 8. Thou shalt be boring, untidy and inelegant at times. 9. Thou shalt not feel guilty. 10. Especially, thou shalt not be thine own worst enemy but thine own best friend.


Self Compassion



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Case Study

Beryl is a 79 year old lady who lives in a care home She has cancer of the breast with lung and liver metastases She has a daughter Julie who is 50 and granddaughter, Emily 25, who visit daily. End of Life discussions have taken place with Beryl and her family in the past. Beryl has become increasingly withdrawn, lethargic and is now bed bound, taking only sips of fluid. Julie has asked if Beryl is dying Emily keeps telling Beryl to ‘ eat and drink’ to ‘get better’

Documents

Priorities for Care of the Dying Person - neleolcare.org