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PalliativeCareGuidelines:Lastdaysoflife|Version231©NHSLothianRe-issuedate:August2010Reviewdate:August2013LastdaysoflifeIntroductionWhenallreversiblecausesforthepatient’sdeteriorationhavebeenconsidered,themulti-disciplinaryteamagreesthepatientisdyingandchangesthegoalsofcare.Reversiblecausestoconsiderinclude:•dehydration•infection•opioidtoxicity•renalimpairment•hypercalcaemia•deliriumClinicalsignsmayinclude:PatientisbedboundIncreasinglydrowsyorsemicomatoseOnlyabletotakesipsoffluidDifficultyswallowingtabletsManagementofadyingpatientandtheirfamilyPlananddocumentcare;considerusingacarepathwayorchecklist.Team•Discussprognosis(patientisdying),goalsofcare(maintainingcomfort)andpreferredplaceofdeathwiththepatientand/orfamily.•Ifdischargehomeispossible,promptandcarefulplanningareneeded.ContactGP,districtnurseandoccupationaltherapisturgently.Medicalstaff•Clarifyresuscitationstatus;checkDNACPRformhasbeencompleted.(See:nationalpolicy)oReassurethepatientandfamilythatfullsupportivecarewillcontinue.•Discontinueinappropriateinterventions(bloodtests,IVfluidsandmedication,vitalsignsmonitoring,frequentbloodsugartests).•Medication–reviewatleastoncedaily.oStopanytreatmentnotneededforsymptomcontrol.oChooseanappropriateroute.Ifabletoswallow,considerliquidformulationsotherwisechangetothesubcutaneousorrectalroute.oConsiderneedforaSCinfusionofmedicationviaasyringepump.oAnticipatoryprescribingofasrequiredmedicationinadvanceforcommonsymptoms.•Hydration:oDiscontinuetubefeeding/fluidsifrespiratorysecretionsarepresent,ifthereisriskofaspirationduetoreducedconsciouslevel,oratthepatient’srequest.oOver-hydrationcontributestodistressingrespiratorysecretions.Artificialfluidsareusuallynotappropriate,butifindicatedcanbegivensubcutaneouslyovernight.(See:Subcutaneousfluids)Nursingstaff•Comfortnursingcare(pressurerelievingmattress,repositionforcomfortonly),eyecare,mouthcare(sipsoffluid,oralgel),bladderandbowelcare.•Explaintothefamilywhythenursingandmedicalcarehasbeenalteredandwhatchangestoexpectinthepatient’scondition.(Seeleaflet:Whathappenswhensomeoneisdying)•Wardteam;recordarrangementsforcontactingthefamilywhenthepatientdeterioratesordies.Communityteam;ensurethefamily/carersknowwhotocontactwhenthepatientdies.•Consideremotional,spiritual/religious,legalandfamilyneedsincludingthoseofchildren.•Identifythoseatincreasedriskinbereavementandseekadditionalsupport.oPreviousmultiplelossesorrecentbereavementoAmbivalentordependentrelationshipoLivingaloneandlackingasupportnetworkoMentalillness,drugoralcoholdependencyoDependentchildren(See:Bereavementonwebsite)PalliativeCareGuidelines:Lastdaysoflife|Version232Re-issuedate:August2010Reviewdate:August2013©NHSLothianSymptomControlinthelastdaysoflifeAnticipatoryprescribingAllpatientsshouldhaveasrequiredmedicationforsymptomcontrolavailable.•OpioidanalgesicSC,hourly;dosedependsonpatient,clinicalproblemandpreviousopioiduse.•1/6thof24hourdoseofanyregularopioid.•Ifnotonaregularopioid,morphineSC2mgordiamorphineSC2mg.•Anxiolyticsedative:midazolamSC2-5mg,hourly.•Anti-secretorymedication:hyoscinebutylbromide(Buscopan)SC20mg,hourly.•Anti-emetic:haloperidolSC0.5mg,12hourlyorlevomepromazineSC2.5-5mg,12hourly.Pain•Paracetamolordiclofenac(asliquid/dispersibleorrectally).NSAIDbenefitsmayoutweighrisksinadyingpatient;canhelpbone,joint,pressuresore,inflammatorypain....