my individualised end of life care plan · pdf file glossary of terms dnacpr do not attempt...

My Individualised End of Life Care Plan

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ContactsCommunity Palliative Care Team

Tel: 01922 602620

Specialist Nurse Practitioner, End of Life Care/Hospital Palliative Care Team

Tel: 01922 721172 ext 7324/7111

Out of hours adviceCompton Hospice

Tel: 0845 2255 497

(Walsall is part of a Black Country, palliative care consultant on call rota for out of hours palliative care advice) St Giles Walsall Hospice

Tel: 01922 602540

Intranet resources• End of Life Care Guidelines

• Breaking Bad News Policy

• Supportive documents from the National End of Life Care Programme, accessed through www.nhsiq.nhs.uk/endoflifecare

Glossary of terms

DNACPR Do Not Attempt Cardio Pulmonary Resuscitation

GP General Practitioner

ICD Implantable Cardioverter Defibrillator

CHC Continuing Healthcare Funding

DS1500 Statement for the department of works and pensions completed by a health care professional, for end of life care

ADRT Advance Decision to Refuse Treatment

LPA Lasting Power of Attorney

MCA Mental Capacity Act

Step 2

Complete the end of life care bundleThis can be completed by a doctor/nurse with the agreement of the named doctor who has overall responsibility for the patient’s medical care.N.B wherever possible this decision should be made at a time where the patient’s multi-professional team are available to discuss.

End of Life Care Responsibility Flow Chart

Step 3

Complete baseline assessmentThis can be completed by a doctor/nurse with the agreement of the named doctor who has overall responsibility for the patient’s medical care.

Step 4

Complete end of life nursing care

plansNursing staff to complete and sign individualised end of life care plans, the plan of care should be evaluated as a minimum on a daily basis.

Step 5

Multidisciplinary evaluationAnybody contributing to the patient’s care should record their actions/involvement in their normal place for evaluation. N.B Remember at all steps the patient and family should be communicated with.

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Step 1

Allocation of lead doctor and nurseA doctor/nurse with lead responsibilities will be allocated to oversee the care of the patient.

PAL 01 – version 1

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Patient name: ...........................................................................................................................

Preferred name: ........................................................................................................................

Patient DOB: .............................................................................................................................

Hospital number: ......................................................................................................................

NHS number: ............................................................................................................................

Responsible consultant/GP: ........................................................................................................

Responsible nurse:......................................................................................................................

Individualised End of Life Care Plan

Completed by

Print name: .....................................................

Signature: ....................................................... Designation: ..................................................

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

Patient Nominated Family Member

Name: ............................................................ Date: ...............................................................

Signature: ..................................................... Relationship: ....................................................

Individualised End of Life Care Plan Commenced

Date: Date:

Name: Name:

Signature: Signature:

Designation: Designation:

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Recognise -The possibility that a person may die within the coming days and hours is recognised and communicated clearly. Decisions about care are made in accordance with the person’s needs and wishes, and these are reviewed and revised regularly by doctors and nurses.

Good practice point - The patient and family should know the names of the senior doctor and nurse looking after them. The treatment plan should be reviewed regularly to ensure that it is still right for the patient; you should respond rapidly to changes in condition, needs and preferences.

Communication - Sensitive communication takes place between staff and the person who is dying and those important to them.

Good practice point - Open, honest and sensitive communication is vital at all times. Communication needs to be two-way and ongoing, it is not just you giving information. You may need time and patience to be able to communicate well with a dying patient.

Involve - The dying person, and those identified as important to them, are involved in decisions about treatment and care.

Good practice point - If the patient lacks capacity to make these decisions, you still need to involve them as much as possible and act in their best interests.

Support - The people important to the dying person are listened to and their needs are respected. Good practice point - Ask about, and listen to, their needs, even if you can’t meet them. Explain what is happening and remember that they may be tired, anxious and fearful.

Plan & do - Care is tailored to the individual and delivered with compassion - with an individual care plan in place.

Good practice point - Document your plan so that it is available to others when needed. Pay attention to symptom control and to physical, emotional, psychological, social, spiritual, cultural and religious needs. Support the person to eat and drink as long as they wish to do so.

Supportive Information for the End of Life Care BundleThe new priorities for care of the dying person state that:

It is important to remember that these priorities all describe ongoing processes, not just a one-off assessment.

Each individual must have an individual care plan according to their needs. The plan should be discussed openly with the person and those identified as important to them. This plan needs to be reviewed on a daily basis.

Remember that the person and their family may need to have more than one conversation about the shared decisions you have made and their continuing care. They also have the right to request a second opinion.

If the individualised plan of care requires review, the same approach in terms of shared decision making should be applied.

Please see page 1 for contact and referral details to the relevant specialist palliative care team.

For further advice and support please refer to the Trust’s end of life guidelines available on the Walsall Healthcare NHS Trust website.

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End of Life Care BundleCaring for the dying patient - starting the processName of the doctor who has overall responsibility for the medical care of the patient

...............................................................................................................................................

You must assess the patient’s mental capacity if you have reason to think it may be impaired. If they lack mental capacity to consent to the treatment plan and have no valid ADRT or LPA, then decisions should be made in their best interests in accordance with the MCA. These assessments and decisions should be documented using the mental capacity documentation which includes the 2-stage mental capacity test and the best interests documentation. This process should be undertaken prior to completion of the end of life care bundle.

1. Recognise. State why it is thought that this patient is dying, who has made that decision and whether all potentially reversible causes have been considered.

2. Communicate. Does the patient give consent for you to speak to the family? State what you have told the patient and family at this point.

3. Involve. How does the dying person wish to be involved in their decisions about their treatment and care? Do they wish family to be involved too?

4. Support. You need to acknowledge and listen to the needs of those important to the dying person. Please document these needs here. Remember to give them the ‘Thinking about End of Life Care’ booklet.

5. Plan and Do. Your conversations above will give you a lot of information. You now need to document your assessment and care plan in the pages that follow.

Signature: Counter signature:

Print name: Print name:

Designation: Designation

Date: Date:

White copy (remains with the patient’s individualised plan) Yellow copy to medical notes/community notes. 4


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Once the end of life care bundle has been completed, this section is for initial assessment.

Patient’s responsible consultant/General Practitioner:

Patient’s responsible named nurse:

Initial Assessment (Page 1 of 3) Comments/action taken

1. Patient comfort: Physical symptoms. Is my patient:

• In pain?• Short of breath?• Coughing?• Vomiting?• Agitated/confused?• Patient oedematous?• Are there any other symptoms distressing

the patient?

2. Key Interventions: The multidisciplinary team have reviewed the need to:

Review and rationalise medication

Commence pre-emptive medication

Commence a syringe pump

Obtain blood tests

Administer intravenous antibiotics

Obtain blood glucose levels

Commence or continue oxygen therapy?

Continue clinical observations?



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Is there a DNACPR order in place? (does this need to be discussed?)

Does the patient have an ICD in place? (See local policy)

3. End of Life Preparation

Has my patient completed in advance:• An Advance Care Plan?• Organ/tissue donation?• Advanced directive?• A will?• Appointed a Lasting Power of Attorney?

4. Preferred Place of Care

Has preferred place of care been discussed?Where is this?

Consider discharge to an alternative care setting if appropriate. Is Fast Track/ CHC Funding in place?

Is the Rapid Discharge Home to Die Pathway appropriate?

5. Patient Comfort: Nutrition

Have nutritional measures been considered?Is my patient hungry? Can my patient eat?Is artificial nutrition in place?Feeding for comfort?

6. Patient Comfort: Hydration

Have hydration measures been considered?

Is my patient:

• Thirsty?• Nauseous?• Vomiting?Can my patient drink?Does my patient have a dry, sore mouth or oral candida?Is artificial hydration in place?



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White copy (remains with the patient’s individualised plan) Yellow copy to medical notes/community notes.

DRAFT


7. Patient Comfort: EliminationIs my patient:

having normal bowel action?passing urine without discomfort?

8. Patient Comfort: Skin Integrity

Does the patient require pressure relieving aids?Is skin intact?Are there any skin changes?Is analgesia required before repositioning?Is the correct bed/mattress in place?

9. Patient Comfort: Spiritual Care Does my patient want:

a spiritual advisor or have any requests?

any religous rituals?

to call people in to say goodbye?

10. Family/Carer Support

Are next of kin/family/carers aware of the plan of care?Have opportunities been provided for sensitive communication and support?Has the carers booklet and diary ‘Thinking about End of Life Care’ been explained and given out?

11. Implementation Plan

Has the plan of care been communicated to the mutidisciplinary team?

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FAXHospital Palliative Care team Walsall Palliative Care Centre

Route 121, Walsall Manor Hospital, Goscote Lane,

Moat Road, Walsall,

Walsall, WS3 1SJ

WS2 9PS

Tel No: 01922 721172 ext 7111 Tel No: 01922 602620

Fax No: 01922 656253 Fax No: 01922 602510

For the Attention of: Specialist Palliative Care Team

From:................................................................ Ward/Community Venue:..................................

Fax number:...................................................... Consultant/GP:..................................................

Telephone number:........................................... .........................................................................

Address:............................................................ .........................................................................

Reference: Individualised End of Life Care Plan

NHS number:

Patient name and address:

Date end of life care plan commenced:

Preferred place of care:

Please send to appropriate hospital or community Specialist Palliative Care Team.

CONFIDENTIAL INFORMATION If received in error please contact sender and destroy copy

This fax is confidential and is intended only for the person to whom it is addressed. If you have received this fax in error, please notify us

immediately by telephone on the number shown on this header sheet, and return the message to us by post. If the reader of this fax is

not the intended recipient, you are hereby notified that any distribution or copying of the message is strictly prohibited.

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Please complete


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Location: Date commenced:

Aim/ProblemTo assess and monitor........................................for the following symptoms:• Pain• Agitation• Nausea & vomiting• Upper respiratory tract secretions• Breathlessness• Other:........................................Ensure a clear plan of care is made involving the whole team to manage individual symptoms.

Things to consider

• Evaluate and discuss benefits and harms• Consider best route (avoid IM) - PO If possible, SC, IV if not• Start with lowest effective dose, titrate as clinically indicated• Consider syringe pump if more than 2-3 as required doses in 24 hours administered• Regularly reassess (at least daily) symptoms and side effects• Seek specialist palliative care advice, if symptoms do not improve or undesirable side effects

Plan of care

Print name: Date:

Signature: Designation:


1. Individual End of Life Care Plan - Symptom ControlName:

DOB:

Hospital No:

NHS No:

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Aim/ProblemEnsure sensitive communication around the current situation is undertaken with......................................../family/friends/carer in a manner that is appropriate to them.

Things to consider/actions:

• Consider the patient’s first language; ensure that appropriate translator services are utilised at key points• Ensure on-going sensitive communication regarding the plan of care takes place at regular intervals

with the patient/family/friends/carers• Allow opportunities for on-going questions or concerns to be addressed• Discuss the carers diary with family/friends/carers; ensure that this is reviewed on a daily basis and that

any issues raised are addressed in a timely manner.

Plan of care

Print name: Date:



2. Individual End of Life Care Plan - CommunicationName:

DOB:

Hospital No:

NHS No:

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Name:

DOB:

Hospital No:

NHS No:


Aim/ProblemTo ensure........................................ is treated with respect and his/her dignity and privacy is maintained in an appropriate manner.

Things to consider/actions

• Personal preferences• Preferred place of care/death• Wishes/beliefs/personal desires (where appropriate)• Family/friend/carer involvement• What is important to them? What are their preferences/thoughts?• Consider side room if patient wishes (where appropriate)

Plan of care

Print name: Date:



3. Individual End of Life Care Plan - Privacy and Dignity

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Name:

DOB:

Hospital No:

NHS No:


Aim/ProblemEnsure........................................is supported to eat as long as they are able to do so. Ensure that........................................nutritional needs are supported and addressed taking into account........................................previous wishes and plans.Include........................................family/friends/carer in discussions and plans around artificial feeding if appropriate/applicable.


• Discuss nutrition/feeding needs and plan with the patient/family/friends/carer and multidisciplinary team• Is the patient feeling hungry? (Consider choices from the snack menu as an alternative)• Is the patient able to eat?• What are the patient’s usual likes and dislikes?• Consider and communicate feeding risks to the patient/family/friends/carers and multidisciplinary team.

Plan of care

Print name: Date:



4. Individual End of Life Care Plan - Nutrition

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Name:

DOB:

Hospital No:

NHS No:


Aim/ProblemEnsure........................................is supported to drink for as long as they are able to do so. If........................................is not able to swallow, decisions about clinically assisted hydration should be made in........................................best interests; consider their prior wishes in consultation with family/friends/carers. Communicate hydration needs and plan clearly with the patient/family/friends/carers. Address any concerns they may have. Ensure this plan of care is evaluated on a daily basis, recognise changes over time.


• Clear communication at this time is essential• Is the patient able to drink? Support the patient to drink if they wish to• Be aware of personal likes and dislikes• Mouth care should be delivered as frequently as required, (refer to mouth care standard operating

procedure including the Trust end of life guidelines)• Does this patient feel thirsty? Are there signs of thirst?• Have hydration measures been considered?• Discuss benefits and harm• Consider a therapeutic trial of clinically assisted hydration

Plan of care

Print name: Date:



5. Individual End of Life Care Plan - Hydration

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Name:

DOB:

Hospital No:

NHS No:


Aim/ProblemTo maintain a level of personal care that is appropriate for........................................and meets........................................current care needs as well as considering his/her usual routines, preferences and likes and dislikes.


• Washing• Mouth care• Eye care• Elimination needs• Hair/personal grooming routines• Usual likes/dislikes• Do those important to the patient wish to be involved in providing personal care?• Conversations and planning regarding large families/amount of visitors.

Plan of care

Print name: Date:



6. Individual End of Life Care Plan - Personal Care

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Name:

DOB:

Hospital No:

NHS No:


Aim/ProblemEnsure that pressure area and skin care is delivered to........................................in accordance with......................................../family/friends /carers wishes and agreement.Support......................................../family/friends/carers with the aim of maintaining comfort by reducing pain and distress.


Patients’ comfort needs around skin integrity will differ from person to person and care should be planned on an individual basis focusing primarily on maintaining comfort and reducing distress.

• Skin changes at end of life can be a reflection of compromised skin• Undertake discussions about skin changes, skin breakdown and pressure ulcers• Respecting and listening to the patient’s/family/carers wishes is important• Completion of wound/pressure ulcer assessment is undertaken • Are there any areas of concern that need to be documented?• Is it appropriate to seek advice from other specialists re: products/aids to be used?• Plan and schedule repositioning/dressing changes according to individualised needs• If patient/family/friends/carers decide against use of pressure relieving aids – document and explain risks

but respect wishes • Infection Control Guidelines where necessary to be adhered to.• Is analgesia required prior to repositioning?• Has this information been relayed to care agency if involved?

Reference : SCALE Final Consensus Statement, October 1, 2009

Plan of care

Print name: Date:



7. Individual End of Life Care Plan - Skin Integrity

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Name:

DOB:

Hospital No:

NHS No:


Aim/Problem Consider and identify the spiritual and religious needs of......................................../family/friends/carers. Ensure this is reviewed on a regular basis taking into account changing needs and priorities.


• Consider the patients/family/friends/carers spiritual and religious needs encompassing psychological, social and emotional care.

• Promote well-being• Explore feelings, such as hopes and fears• Explore religious beliefs and whether they would value support with their faith including prayer and

rituals• Consider specific practices important to the patient• Consider their wishes to make funeral or other practical arrangements• Consider referral to spiritual leader, chaplain, counsellor, psychologist or complementary therapies.

Plan of care

Print name: Date:



8. Individual End of Life Care Plan - Spiritual and Religious Care

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Aim/ProblemTo deliver dignified care after death to......................................../family/friends and carers, taking into account their individualised wishes and beliefs.


• Cultural, religious and spiritual beliefs• The patient’s wishes about organ and tissue donation• Care of the deceased - refer to the Trust’s standard operating procedure for care after death (found on

intranet)• Bereavement information, advice and support; provide bereavement leaflets and information on

collection of the death certificate• Completion of relevant documentation e.g. within the hospital complete the mortuary passport• Consider infection control concerns• Notify relevant teams/services as appropriate of the patient’s death.

Plan of care

Print name: Date:



Name:

DOB:

Hospital No:

NHS No:

9. Individual End of Life Care Plan - Care after Death

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Aim/Problem


Plan of care

Print name: Date:



Name:

DOB:

Hospital No:

NHS No:

10. Individual End of Life Care Plan -

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Care Plan No:

Review plan of care:

Signature: Print: Designation: Date:

Care Plan No:



Care Plan No:




Name:

DOB:

Hospital No:

NHS No:

Review of Care Plans

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1.#If#on#Morphine#and#unable#to#swallow#prescribe#Diamorphine#by#S/C#infusion#via#syringe#pump#

! Calculate#the#amount#(mg)#of#oral#Morphine#normally#taken#in#24#hours#

! Divide#this#total#by#3#to#calculate#the#equivalent#of#S/C#Diamorphine#for#24#hours#

! (eg.#patient#taking#90mg#oral#Morphine#BD#=#180mg#over#24hrs#=#60mg#S/C#Diamorphine#/24#hours#via#syringe#pump)#

2.#Prescribe#PRN#S/C#Diamorphine#for#break#through#pain#

! Calculate#this#dose#by#dividing#the#total#24#hour#dose#of#Diamorphine#by#6##

! (eg.#60mg#÷#6#=#10mg#PRN)##

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#

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Titrate#the#dose#of#Diamorphine#in#the#syringe#pump:#

! Add#the#total#dose#of#S/C#Diamorphine#given#PRN#in#the#previous#24#hours#to#the#amount#in#the#syringe#pump##

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####

############################ #### ##### ############

Guidelines#for#the#Management#of#PAIN#in#the#Dying#Phase#

Has#the#patient#been#taking#Morphine#for#pain?##

Yes( No(

Is#the#patient#currently#in#pain?#

#

No(Yes(

Guidelines#for#the#Management#of#PAIN#in#ADVANCED#KIDNEY#DISEASE#

If#two#or#more#doses#are#required#over#24#hours#commence#a#syringe#pump#with#Alfentanil.###Alfentanil#is#less#likely#than#other#opioids#to#cause#problems#in#renal#failure.#It#does#not#have#active#metabolites#and#has#a#short#acting#effect,#however#because#of#this#short#acting#effect#it#is#not#suitable#for#PRN#doses.###

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! Continue#with#PRN#Oxycodone#S/C#or#PRN#Diamorphine#S/C#in#reduced#doses#(as#advised#in#box#above)#Be#aware#the#effect#may#last#longer#than#in#patients#with#normal#renal#function##

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Symptoms(persisting(

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#

Administer:#! Oxycodone#1V2mg#S/C##

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#

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######

############## ######## ####################

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Guidelines)for)the)Management)of)NAUSEA)and)VOMITING)in)the)Dying)Phase)

Is)the)patient)experiencing)nausea)and/or)vomiting?))

In)anticipation)of)future)symptoms)prescribe)S/C)

Levomepromazine)6.25mg)PRN)(up)to)25mg/24)hours))

)

Assess)for)cause:)1.)Does)the)patient)usually)take)oral)antiemetics?)

! If)yes)continue)by)an)alternative)route)ie.)via)syringe)pump)

2.)Could)the)patient)have)bowel)obstruction?)If)Yes:)! Avoid)proVkinetic)antiemetic)ie.)

Metoclopramide))! Stop)stimulant)laxatives)! SEEK)ADVICE)FROM)PALLIATVE)CARE)

TEAM)3.)Are)symptoms)persisting)with)no)specific)cause)identified?)

! Administer)6.25mg)S/C)Levomepromazine)! Prescribe)S/C)Levomepromazine)6.25mg)

PRN)(up)to)25mg/24hrs)))

Contact)Specialist)Palliative)Care)Team)for)further)advice.))

If)the)patient)has)required)two)or)more)doses)in)24)hours)commence)a)syringe)pump)with)Levomepromazine)

! Starting)dose)Levomepromazine)12.5V25mg/24)hours)! In)frail/cachexic)patients)6.25mg/24)hours)may)be)

sufficient))

! Continue)PRN)doses)! Dose)in)pump)may)need)titrating)up)against)symptom)

control))


))))))

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Second)line)medication)option:))

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Yes(

In)anticipation)of)future)symptoms)prescribe)Haloperidol)0.5V1.5mg)S/C)PRN)

(up)to)3mg/24)hours)))

Is)the)patient)experiencing)nausea)and/or)vomiting?))

No(

21

Treat&reversible&causes;&exclude:&• Severe&pain&• Full&rectum&• Full&bladder&• Lying&position&in&patient&with&dyspnoea&&

In&anticipation&of&future&agitation&prescribe&Midazolam&S/C&2.5F5mg&PRN&

! Reassess&regularly&&

Where&anxiety&is&predominant:&&! Administer&2.5F5mg&S/C&Midazolam&&

! (Use&5mg&if&patient&previously&on&benzodiazepines)&

! Prescribe&Midazolam&2.5F5mg&S/C&PRN&

&

Where&delirium&and&psychotic&features&are&predominant:&

! Administer&Levomepromazine&S/C&6.25F12.5mg&PRN&

! Prescribe&Levomepromazine&S/C&6.25F12.5mg&PRN&

&

ANXIETY(predominant((

Features(of(DELIRIUM(

predominant(

Consider&if&anxiety&or&delirium&is&a&predominant&feature&


! If&two&or&more&doses&required&in&24&hours&commence&a&syringe&pump&with&Levomepromazine&

! Starting&dose&Levomepromazine&S/C&12.5F25&mg/24&hours&&

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&&&&&&&& &&&

&& &&&&&&&& &&&&&&&&&&&&&&&&&&&

&&&&&&&&&&&

Guidelines&for&the&Management&of&AGITATION&in&the&Dying&Phase&

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No(Yes(

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! Starting&dose&Midazolam&S/C&5F10mg/24&hours&(Or&10F20mg&S/C&over&24&hours&if&patient&previously&on&benzodiazepines)&&


Guidelines&for&the&Management&of&AGITATION&in&ADVANCED&KIDNEY&DISEASE&

Treat&reversible&causes;&exclude:&• Severe&pain&• Full&rectum&• Full&bladder&• Lying&position&in&patient&with&dyspnoea&

Agitation(persisting(&

! Administer&S/C&Midazolam&2.5mg&&! Prescribe&S/C&Midazolam&2.5mg&PRN&&

If&two&or&more&doses&required&in&24&hours&consider&a&syringe&pump&with&Midazolam:&

! Starting&dose&Midazolam&S/C&5F10mg/24&hours&! Continue&PRN&doses&! Dose&in&pump&may&need&titrating&up&against&symptom&control&&



&&& &&&&&&&&&&

&&&&&&&&&&&&


Yes( No(

In&anticipation&of&future&symptoms&of&agitation&prescribe&Midazolam&S/C&2.5mg&PRN&


Contact&Specialist&Palliative&Care&Team&for&further&advice.&&


CarePlanA417.indd 22 08/03/2016 10:25

Treat&reversible&causes;&exclude:&• Severe&pain&• Full&rectum&• Full&bladder&• Lying&position&in&patient&with&dyspnoea&&

In&anticipation&of&future&agitation&prescribe&Midazolam&S/C&2.5F5mg&PRN&


Where&anxiety&is&predominant:&&! Administer&2.5F5mg&S/C&Midazolam&&

! (Use&5mg&if&patient&previously&on&benzodiazepines)&

! Prescribe&Midazolam&2.5F5mg&S/C&PRN&

&

Where&delirium&and&psychotic&features&are&predominant:&

! Administer&Levomepromazine&S/C&6.25F12.5mg&PRN&

! Prescribe&Levomepromazine&S/C&6.25F12.5mg&PRN&

&

ANXIETY(predominant((

Features(of(DELIRIUM(

predominant(

Consider&if&anxiety&or&delirium&is&a&predominant&feature&


! If&two&or&more&doses&required&in&24&hours&commence&a&syringe&pump&with&Levomepromazine&

! Starting&dose&Levomepromazine&S/C&12.5F25&mg/24&hours&&


&


&&&&&&&& &&&

&& &&&&&&&& &&&&&&&&&&&&&&&&&&&

&&&&&&&&&&&

Guidelines&for&the&Management&of&AGITATION&in&the&Dying&Phase&


No(Yes(

Contact&Specialist&Palliative&Care&Team&for&further&advice.&&Note:&Severe&agitation&is&often&resistant&to&the&effects&of&sedatives&and&may&need&repeated&doses&or&a&combination&of&both&antipsychotic&and&benzodiazepine&medications.&&

If&two&or&more&doses&required&in&24&hours&commence&a&syringe&pump&with&Midazolam&&

! Starting&dose&Midazolam&S/C&5F10mg/24&hours&(Or&10F20mg&S/C&over&24&hours&if&patient&previously&on&benzodiazepines)&&


Guidelines&for&the&Management&of&AGITATION&in&ADVANCED&KIDNEY&DISEASE&

Treat&reversible&causes;&exclude:&• Severe&pain&• Full&rectum&• Full&bladder&• Lying&position&in&patient&with&dyspnoea&


! Administer&S/C&Midazolam&2.5mg&&! Prescribe&S/C&Midazolam&2.5mg&PRN&&

If&two&or&more&doses&required&in&24&hours&consider&a&syringe&pump&with&Midazolam:&

! Starting&dose&Midazolam&S/C&5F10mg/24&hours&! Continue&PRN&doses&! Dose&in&pump&may&need&titrating&up&against&symptom&control&&



&&& &&&&&&&&&&

&&&&&&&&&&&&


Yes( No(

In&anticipation&of&future&symptoms&of&agitation&prescribe&Midazolam&S/C&2.5mg&PRN&


Contact&Specialist&Palliative&Care&Team&for&further&advice.&&

22


CarePlanA417.indd 23 08/03/2016 10:25

In#anticipation#of#future#symptoms,#prescribe:#

! Hyoscine#butylbromide#S/C#20mg#PRN#up#to#120mg/24#hours#

Or#! Glycopyrronium#S/C#0.2mg#PRN#up#

to#1.2mg/24#hours###

Explanation#and#reassurance#for#relatives#and#carers#

Consider#nonIpharmacological#interventions:##

! Repositioning#the#patient#! Discontinuing#artificial#hydration#

(this#worsens#secretions)#Note:#Suction#rarely#helps#

#


Administer:#! Hyoscine#butylbromide#S/C#20mg#PRN#up#to#120mg/24#hours#Or#! Glycopyrronium#S/C#0.2mg#PRN#up#to#1.2mg/24#hours##

#


Symptoms(and/or(concerns(resolved(

###

#

############ ## ######################

#######

#####

Guidelines#for#the#Management#of#SECRETIONS#in#the#Dying#Phase#

Are#respiratory#tract#secretions#causing#noisy#breathing#that#is#distressing?##

Yes( No(

If#two#or#more#doses#required#in#24#hours#commence#a#syringe#pump:#

! Hyoscine#butylbromide#S/C#60I120mg/24#hours#

Or#! Glycopyrronium#S/C#0.6I1.2mg/24#

hours###

! Continue#PRN#medication#! Dose#in#pump#may#need#titrating#up#

against#symptom#control.##

Contact#Specialist#Palliative#Care#Team#for#

further#advice.##

In#anticipation#of#future#symptoms,#prescribe:#

! Hyoscine#butylbromide#S/C#20mg#PRN#up#to#120mg/24#hours#

Or#! Glycopyrronium#S/C#0.2mg#PRN#up#

to#1.2mg/24#hours###

Explanation#and#reassurance#for#relatives#and#carers#

Consider#nonIpharmacological#interventions:##

! Repositioning#the#patient#! Discontinuing#artificial#hydration#

(this#worsens#secretions)#Note:#Suction#rarely#helps#

#


Administer:#! Hyoscine#butylbromide#S/C#20mg#PRN#up#to#120mg/24#hours#Or#! Glycopyrronium#S/C#0.2mg#PRN#up#to#1.2mg/24#hours##

#


Symptoms(and/or(concerns(resolved(

###

#

############ ######################

#######

#####

Guidelines#for#the#Management#of#SECRETIONS#in#ADVANCED#KIDNEY#DISEASE#

Are#respiratory#tract#secretions#causing#noisy#breathing#that#is#distressing?##

Yes( No(

If#two#or#more#doses#required#in#24#hours#commence#syringe#pump:#

! Hyoscine#butylbromide#S/C#60I120mg/24#hours#

Or#! Glycopyrronium#S/C#0.6I1.2mg/24#

hours###

! Continue#PRN#medication#! Dose#in#pump#may#need#titrating#up#

against#symptom#control##

Contact#Specialist#Palliative#Care#Team#for#

further#advice.##

23


CarePlanA417.indd 24 08/03/2016 10:25

Consider)non*pharmacological)interventions:)

• Position)• Fan)therapy)

)Manage)respiratory)tract)secretions)

Is)the)patient)already)taking)oral)opioids?)

Yes$No$

No$

! Administer)Diamorphine)S/C)2.5*5mg))Prescribe:))! Diamorphine)S/C)2.5*5mg)PRN)! Midazolam)S/C)2.5*5mg)PRN)for)symptoms)of)

distress/anxiety)caused)by)breathlessness)

Symptoms$persisting$

If)the)patient)has)required)two)or)more)doses)in)24)hours)commence)a)syringe)pump:))

! Usual)starting)dose)of)Diamorphine)S/C)in)syringe)pump)5*10mg/24)hours)! Add)Midazolam)if)breathlessness)is)associated)with)distress/anxiety)! Continue)PRN)medication)! Dose)in)pump)may)need)titrating)up)against)symptom)control)

)


NB.)Depending)on)the)patient’s)individual)needs)the)doses)for)pain)and)dyspnoea)may)be)different)and)the)medication)sheet)needs)to)be)specific)so)that)the)correct)

dose)and)frequency)is)prescribed)and)given)appropriately.))


Contact)Specialist)Palliative)Care)Team)for)advice.)

)

Yes$

No$

))) ))))) )))))) )))))) )) ) )))))))))))))))))

))

))))))))))))))

Guidelines)for)the)Management)of)BREATHLESSNESS)in)the)Dying)Phase)

Is)the)patient)breathless)and)distressed?))

Yes$ No$

In)anticipation)of)future)breathlessness)prescribe:)

! Diamorphine)S/C)2.5*5mg)PRN)Or)! Normal)PRN)dose)of)S/C)Diamorphine)if)

using)it)regularly)And)! Midazolam)S/C)2.5*5mg)PRN)for)

symptoms)of)distress/anxiety)caused)by)breathlessness)

)

Is)the)patient)breathless)and)distressed?))

Guidelines)for)the)Management)of)BREATHLESSNESS)in)ADVANCED)KIDNEY)DISEASE)

Yes$ No$

Consider)non*pharmacological)interventions:)• Position)• Fan)therapy)

)Manage)respiratory)tract)secretions))

Is)the)patient)already)taking)oral)opioids?)

Administer:)! Oxycodone)S/C)1*2mg)or)Diamorphine)S/C)1.25*2.5mg))

Prescribe:)! Oxycodone)S/C)1*2mg)PRN)or)Diamorphine)S/C)1.25*2.5mg)PRN))

And)! Midazolam)S/C)1.25*2.5mg)PRN)for)distress/anxiety)associated)with)breathlessness))

)

Contact)Specialist)Palliative)Care)Team)for)advice.)

)

Prescribe:)! Oxycodone)1*2mg)S/C)PRN)

Or)! Diamorphine)1.25*2.5mg)S/C)PRN))

And)! Midazolam)1.25*2.5mg)S/C)PRN)for)

distress/anxiety)symptoms)associated)with)breathlessness))

No$

If)two)or)more)doses)are)required)over)24)hours)commence)a)syringe)pump)with)Alfentanil.)))Alfentanil)is)less)likely)than)other)opioids)to)cause)problems)in)renal)failure.)It)does)not)have)active)metabolites)and)has)a)short)acting)effect,)however)because)of)this)short)acting)effect)it)is)not)suitable)for)PRN)doses.)))

! Usual)starting)dose)of)Alfentanil)in)a)syringe)pump)0.5)*1mg)over)24)hours))(Equivalent)to)5*10mg)of)Diamorphine)and)4*8mg)Oxycodone).)

! Alfentanil)0.125mg)=)Diamorphine)1.25mg)=)Oxycodone)1mg)! Consider)adding)midazolam)for)distress/anxiety)associated)with)breathlessness))! Continue)with)PRN)Oxycodone)S/C)or)PRN)Diamorphine)S/C)in)reduced)doses)(as)advised)

in)box)above).)Be)aware)the)effect)may)last)longer)than)in)patients)with)normal)renal)function.)! Dose)in)pump)may)need)titrating)up)against)symptom)control)

)


))))))))))) )))))))))))

)))))))))) )))))) )

Yes$


24


CarePlanA417.indd 25 08/03/2016 10:25

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CarePlanA417.indd 26 08/03/2016 10:25

my individualised end of life care plan · pdf file glossary of terms dnacpr do not attempt...

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