Excellent Care at the End of Life - Wirral CCG

Excellent Care at the End of LifeWirral Multidisciplinary Record and Prompt

for Adult Care in the Last Days of Life

Wirral Community Health & Care NHS Foundation Trust

Monday - Friday9.00am - 5.00pm0151 328 0481

Weekend/Bank Holiday (Professional only) 07880446498

Wirral Hospice St John’s

Monday - Sunday5.00pm - 9.00am0151 343 9529

This document should be used to guide care and communication for patients who are likely to be in the last days of life, and those who are close to them. The approach is based on national guidance including the Leadership Alliance Priorities for Care of the Dying Person (2014), and

NICE Guidelines for Care of the Dying Adult (2015).

Further advice and support is available from Specialist Palliative Care 24 hours a day, 7 days a week via the following telephone numbers:

Patient DemographicsPatient Name:

D.O.B.:

MRN No.:

NHS No.:

Address:

Leaflets

Please tick to confirm the following leaflets have been given to the patient or those close to them:

• What to expect when someone important to you is dying

• Leaflet explaining the Care Record

Wirral UniversityTeaching Hospital

NHS Foundation Trust



GP Name:

GP Surgery:

Community Nursing Team:

DN No:

Signature list for all healthcare professionals documenting within this individualised care plan (this document replaces all other clinical records and is for use by the whole multi-disciplinary team):

Name Designation Signature

Initial Assessment

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D.O.B.:

MRN No.:

NHS No.:

Please discuss with the patient and/or those close to them that recording care within this document is recognised as best practice within Wirral when caring for dying patients. The accompanying leaflet describing this care record should be given. If they do not wish care to be recorded in this way, please continue to document care within the usual clinical record.

Please record the name(s) of the person(s) you have discussed the use of this document with here:

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This initial assessment must be completed in full as soon as possible after the dying phase is recognised. This is a shared responsibility between medical and nursing teams. The lead clinician must ensure this is carried out in a timely fashion.

Professionals involved in the recognition of dying phase:We feel that this person is likely to be in the last hours or days of life, and agree that their care would be best supported by the use of this individualised care plan:

Doctor: Designation: Sign: Date:Time:

Nurse’s name: Designation: Sign: Date:Time:

Lead clinician signature: this document must be signed by the responsible senior clinician (usually the named GP) within 24 hours of the individualised care plan commencing.

Print name: Designation: Sign: Date:Time:

If not signed within 24 hours, please discuss with lead clinician & document here:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Is there a DoLS authorisation in place for this patient currently? Yes No

If you have any reason to doubt the patient’s capacity to make treatment decisions, please adhere to local policy for safeguarding and complete necessary documentation.

Where it is established that the dying person lacks capacity to make a particular decision, that decision or action taken on their behalf must be in their best interests. Involve them as far as possible.

Initial Assessment

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D.O.B.:

MRN No.:

NHS No.:

Does the patient have a permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD) in situ?

Yes No If ICD in situ, has this been de-activated?(state which device)……………............. Yes No

If no, please seek urgent advice: Out of Hours

Coronary Care Unit Ext: 2141 OR On Call Cardiologist via switchboard

Is a Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) order in place?

Yes No

If no, please document reasons for this here, and consider seeking a second opinion:

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Location

Advance Decision to Refuse Treatment (ADRT)

Advance Care Plan / Anticipatory Care Plan

Lasting Power of Attorney for Health & Welfare

‘This Is Me’ document (Dementia Patients)

Initial Assessment

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Does the patient have any of the following documents?


D.O.B.:

MRN No.:

NHS No.:

Monday - Friday 09:00 - 17:00Cardiovascular Department Ext: 8225

Routine observations:

It is usually appropriate to discontinue routine observations in the dying phase. Please consider whether any ongoing observations are indicated, and if so document here:

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Initial Assessment

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Please consider who will complete the death certificate from within the clinical team, and consider what will be recorded as the cause(s) of death. Seek senior advice in advance if necessary.


D.O.B.:

MRN No.:

NHS No.:

Priority: RECOGNISE‘The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with theperson’s needs and wishes, and those are regularly reviewed and decisions revised accordingly. Always consider reversible causes e.g. infection, dehydration, hypercalcaemia etc.’

Please document below the reason you feel this patient is dying, including consideration of potentially reversible causes (unless already recorded elsewhere within the clinical record).

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Priority: COMMUNICATE‘Sensitive communication takes place between staff and the dying person, and those identified as important to them.’ Ensure communication is regular, pro-active and two way.

What has been communicated to the dying person? If not discussed, please record reasons for this. How did they respond to this information (if given)?

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What has been communicated to those close to the dying person (family members or close friends)? Remember to use clear language, including the word ‘dying’).How did they respond to this information?

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Initial Assessment

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What do the patient and those close to them feel is most important at this time? (What gives the patient comfort e.g. certain radio/TV programmes, music, personal care)?

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Does the patient have any specific religious needs?

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Preferred place of death (PPD):

Hospital Hospice Home Other ..........................................

Care Home Unable to ascertain (Please state reason below)

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If the person is not in their PPD, is it appropriate / possible to consider transfer at this time?

Yes No (Please state reason below)

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D.O.B.:

MRN No.:

NHS No.:

Priority: INVOLVE‘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.’

Priority: SUPPORT

How are those close to the patient coping in this situation? Is there anything specific we could do to support those close to the patient at this time? (e.g. Would they benefit from Specialist Palliative Care support? Do they have any spiritual care needs? Would they like to see their local religious leader? Would they appreciate the assistance of Hospice @ Home)

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Priority: PLAN & DO‘An individual plan of care, which included food and drink, symptom control and psychological, social and spiritual support is agreed, co-ordinated and delivered with compassion.’

INITIAL ASSESSMENT

Comfort: Please comment specifically on the presence/absence of the five common symptoms in dying patients (pain, agitation, nausea, dyspnoea, respiratory tract secretions).

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Nutrition/Hydration: Is the patient receiving any form of artificial nutrition or hydration currently? Is it appropriate to continue this? Please document their current hydration status, (you may wish to take into account the presence or absence of the following: thirst; dry mouth; concentrated urine; previously deranged U&E; respiratory tract secretions; pleural effusion; pulmonary oedema; peripheral oedema; ascites). If clinically assisted hydration is required, this should be at a volume of 1litre in 24 hours.

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Initial Assessment

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


D.O.B.:

MRN No.:

NHS No.:Patie

nt Sticker

Initial Assessment

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Oral Hygiene: Please document an assessment of the patient’s oral hygiene needs and plan to maintain this. Is this an aspect of care those close to the patient could support with?

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Bladder & Bowel Function: Are there any additional actions required to promote comfort? (e.g. Is there a catheter is situ? When did the patient last open their bowels?).

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The patient must be supported to eat and drink for as long as this is possible and wished for.


D.O.B.:

MRN No.:

NHS No.:

Medication: Please rationalise medication (only continue drugs which are likely to contribute to symptom management), and discontinue oral medication completely if the patient is unable to swallow. Prescribe symptom control medication via the subcutaneous route according to ‘Care of the Dying Symptom Control Guidance’, and document a summary of prescribing decisions here:

Date: ....................................... Time: ....................................... Sign: ........................................

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REGULAR NURSING ASSESSMENT

Ongoing Regular Assessment

Has the patient been supported to eat and drink? If this has not been possible, please document

the reason:………………………………………………………………………………….................................

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Please Assess the Following

DESCRIBE ACTION TAKENTime: Time:

Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function

Mouth problem (e.g. dry mouth,

oral candida)

Skin Integrity (follow local

policy)

DateTimeSign

DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

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the reason:………………………………………………………………………………….................................

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DATE: .......................


D.O.B.:

MRN No.:

NHS No.:



Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function


oral candida)


policy)

DateTimeSign

DAILY REVIEW

Is it still appropriate to use this individualised care plan?

(Do you still feel the patient is in the last days of life?) Yes No

If no, please discontinue immediately and revert to usual documentation within your care setting.Please review the patient and assess for the five common symptoms (pain, nausea / vomiting, dyspnoea, agitation and chest secretions). Or any issues highlighted within Nursing Reviews. Remember to seek reversible causes (e.g. urinary retention causing agitation):

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Are any adjustments to the patient’s symptom control medication required? Please review PRN requirements, make necessary adjustments according to symptom control guidance and document your decision making:

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Please document an assessment of the patient’s nutrition/hydration status (refer to guidance on p.8):

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How are the patient and those close to them coping emotionally? Are there any additional social or spiritual needs?

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Is Specialist Palliative Care input required at this time? (Contact details on front page).

Yes No If yes, please document time of referral:…………..

Please use separate continuation sheets to document any additional assessments by members of the MDT, significant conversations or events.

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DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

Date: ....................................... Time: ....................................... Sign: ........................................

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Date Sign

Continuation Sheet

Time

Patient demographics

Patient name:

D.O.B.:

MRN No.

NHS No.:

Please use this space to document any additional care given, significant conversations or events.

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the reason:………………………………………………………………………………….................................

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Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function


oral candida)


policy)

DateTimeSign

DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

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the reason:………………………………………………………………………………….................................

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Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function


oral candida)


policy)

DateTimeSign

DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

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DAILY REVIEW




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MRN No.:

NHS No.:

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Continuation Sheet

Time


Patient name:

D.O.B.:

MRN No.

NHS No.:


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the reason:………………………………………………………………………………….................................

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Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function


oral candida)


policy)

DateTimeSign

DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

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the reason:………………………………………………………………………………….................................

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Pain/Discomfort

Nausea/Vomiting

Dyspnoea

Chest secretions

Agitation

Emotional Needs

Urinary Function

Bowel Function


oral candida)


policy)

DateTimeSign

DATE: .......................


D.O.B.:

MRN No.:

NHS No.:

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DAILY REVIEW




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DATE: .......................


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MRN No.:

NHS No.:

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Continuation Sheet

Time


Patient name:

D.O.B.:

MRN No.

NHS No.:


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Glossary of Terms for the ROC in The Community Setting

NICE – National Institute of Health and Care Excellence

ADRT – Advanced decision to refuse treatment

ACP – Advanced care plan

LPA – Lasting power of Attorney – legal document that lets a patient appoint one or more

people to help make decisions on their behalf. There are two types of LPA, one for

health & welfare and one for property & financial affairs

DoLs – Deprivation of Liberty Safeguards are a set of safeguards that allow hospitals and

care homes to take away a patient’s liberty in order to prevent them coming to harm

PPM – Permanent Pacemaker

ICD – Implantable Cardiac Defibrillator

DNACPR – Do Not Attempt Resuscitation

Hypercalcaemia – High levels of calcium in the blood

Urinary retention – Inability to pass urine

PPC – Preferred place of care, the place a patient would like to be cared for in their last

days of life

PPD – Preferred place of death, the place a patient would like to be when they die

U&E – Urea & Electrolytes – blood test of kidney function

Pleural Effusion – Localised collections of fluid at the bases of the lungs

Pulmonary Oedema – Collection of fluid in the lungs.

Peripheral Oedema – Collection of fluid in the peripheral tissues, usually the legs.

Ascites – Collection of fluid in the abdominal cavity

Clinically assisted hydration – Fluids delivered usually under the skin to help hydrate a patient

Subcutaneous route – A method of delivering medication or fluid under the skin

Dyspnoea – Feeling of breathlessness

Oral Candida – Thrush Infection in the mouth

Author: Dr xxxxxxxxxxxExcellent Care at the End of Life: Wirral Multidisciplinary Record and Prompt for Care in the Last Days of Life: Version 2Date of V1 Publication: April 2016. V2.2 April 2018Date for Review: April 2020

Wirral Record of Care in the Last Days of LifeInformation for patients and those close to them

What is the Wirral Record of Care and when is it used?The Wirral Record and Prompt for Care is an individualised care plan. It is used when it is recognised that a person may have entered the last hours or days of life.

Before using this document, your healthcare team will carefully consider whether there are any treatable causes for your or your loved one’s poorly condition. When it is not possible to reverse the underlying problem and a person is recognised to be dying, it is important that you are offered the right care and support.

The plan of care will be reviewed regularly, and if your condition improves, your treatment may be changed. Your comfort will also be reviewed on a regular basis.

What is the purpose of the Wirral Record for Care in the Last Days of Life?The purpose of the record is to guide care and communication between healthcare professionals, patients and those close to them.

It is important to us that you and those close to you are as involved in decisions about the care you receive as you wish to be. The record of care provides space for your team to write down discussions they have with you and those close to you, to ensure that your needs and wishes are recorded. It also prompts them to ensure regular assessment of your physical comfort (including eating and drinking), spiritual and social needs.

We recognise that this is a challenging time for those close to you. The care record can be used to help health care professionals understand the difficulties families and friends may be facing at this time and ensure we provide the support they need.

How was this care record developed?This document was developed by an experienced team of healthcare professionals working within hospital, hospice and community services in Wirral, and is based on national guidance including NICE Guidelines for Care of the Dying Adult and Leadership Alliance Priorities for Care of the Dying Person.

Who can I contact if I have further questions or need more support at this time?There may be more questions you would like to ask, or you may be worried about something. We would like to talk with you, answer any questions you have, and support you. Please tell the staff looking after you if you would like to speak with someone, and they will arrange for the person best placed to answer your questions to meet with you.





Excellent Care at the End of Life - Wirral CCG

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