1 Physical care at the end of life. 2 Welcome Note of caution o Talking about last days of life is hard – professionally as well as personally o This.

1Physical care at the end of life

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• Welcome

• Note of caution

o Talking about last days of life is hard – professionally as well as personally

o This session is designed to help you so you can help your patients and those important to them

o If you feel upset or emotional that is okay – you are encouraged to stay and we will help but if you must leave please speak to a friend or colleague so you have some support

Introduction and note of caution

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• Describe how to provide respectful care for a dying person:o maintaining dignityo Understand the patient who is dying may still be able to hear, even if they

are unable to respond

• Describe the key principles of gentle, sensitive care including:o repositioning, personal hygiene, skin care, continence care, monitoring

and observation, good oral care

• Explain how to support family with personal care for the patient if they wish to do so

• Explain how to assess, tailor and document regular monitoring of patient’s:o symptoms, comfort, hygiene, observations and ongoing interventions

Objectives

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Communicating with and respecting the dying patient

What is the first thing you, as a health care professional, should do upon entering a room or bed space of an unresponsive patient who is dying?

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Communicating with and respecting the dying patient

• Introduce self and role to patient and others in the room

• Sensitively communicate with the dying person, and those identified as important to patient

• Talk as if the patient can hear you, even if he/she appears to be unconscious or restless. The patient may also be aware of people around them

• Simple, respectful explanations of the care you will be providing remain important elements of care

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Consider for a moment you are the dying patient in the bed

1. What would be important to you at this time?

2. If you could talk to the people who are caring for you, what would you tell them?

3. What would “good care” look like to you?

Delivering sensitive, gentle personal care

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• An unconscious patient at the end of life is wholly dependent on you to meet their personal care needs

• Care must be patient centred, individualised and take into account any religious, spiritual and cultural beliefs, values and norms

For terminally ill patients, dissatisfaction with care is often related to ‘the devaluing, dehumanising effect of inadequately

provided personal care’ (Rogers et al, 2000)

Delivering sensitive, gentle personal care

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Delivering sensitive, gentle personal care: continence care

• Goal of continence care is ensuring the patient is comfortable and dry, paying attention to skin and pressure areas

• Poorly managed bowel and bladder care can cause several complex difficulties for the patient

• An indwelling catheter and/or absorbent pads and/or convene/sheath may be used

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Delivering sensitive, gentle personal care: Skin care and repositioning

• Patients at the end of life are at significant risk of skin damage and breakdown

• Skin care at this time has three main components: assessment, cleansing and positioning

• The patient should only be repositioned to maintain comfort

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Delivering sensitive, gentle personal care: vital signs and observations

• Ask: How likely is it that this investigation or treatment will help this patient at this time?

• The multidisciplinary team must discuss, together with the patient and persons important to them, the appropriateness of continuing vital sign monitoring and observations, including blood tests

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The importance of good oral care

• Why might a patient be at risk of poor oral hygiene at the end of life?

• What would you include in an oral hygiene care plan for a patient at the end of life?

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The importance of good oral care

• A healthy mouth is clean, moist, and pain free. Oral care should focus on:o patient's comforto be tailored to individual needo be discontinued if causing distress

• 1-2 hourly mouth care is advised if a patient too unwell to undertake good oral care

• Mouth care can be carried out by the family / those important to the patient

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Recommendations for oral hygiene care

• To clean teeth: use a small headed soft bristle toothbrush or foam sponge if a toothbrush isn’t tolerated

• To clean the oral mucosa: use a moist foam swab

• If the patient becomes agitated or distressed, discontinue the procedure

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Support the people important to the patient to provide personal care

• If the people important to the patient wish to be involved in the patient’s physical care, what are the advantages of this:o for the patiento for family and persons important to the patiento for health care professionals?

• Discuss how to involve and support persons important to the patient in the patient’s care

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‘Most of the time I was by his bed, helping with the nursing and being allowed to continue to care and support him as I have done for many years... Above all I was with him at the end of his life.’

Family member

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Ask:

How can we work together to best look after [the name of the person being cared for]?

• Actively explore, respect and meet where possible the needs of families and others identified as important to the patient

• Persons important to the patient have their own needs which can be overlooked at this time; including anxieties, fears, feeling distressed, emotional and physically exhausted

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Regularly monitor symptoms and comfort, providing individualised care

• Agree, co-ordinate and deliver with compassion an individual plan of care

• Assess at least every four hours in accordance with the patient’s wishes and the wishes of those important to them

• Documenting individualised care will improve the quality of care provided

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Activity

List non-verbal signs of discomfort and pain that a patient thought to be at the end of life may demonstrate

19Physical care at the end of life