Recognising Dying in Community Hospitals
1.1The national guidance “One Chance to Get it Right” sets out five priorities for care of the dying person encompassing recognition of dying, communication with the patient and their family, involving the patient and family in decision-making, addressing the needs of the family and delivering an individualised, holistic end of life care plan.
1.2Priority 1 states:“When a person’s condition deteriorates, unexpectedly, and it is thought they may die soon, i.e. within a few hours or very few days, they must be assessed by a doctor who is competent to judge whether the change is potentially reversible or the person is likely to die. if the change in condition is potentially reversible, prompt action must be taken to attempt this, provided that is in accordance with the person’s wishes or in their best interests if it is established that they lack capacity to make the decision about treatment at that time.”
1.3The essence of this standard of care is two-fold: the prevention of avoidable death and preparation of the patient and family that death is a likely outcome. It highlights the important role of the doctor in assessing a patient whose deterioration is unexpected. Nurses are skilled at recognising that a patient is dying but it is imperative that reversible causes are excluded before a palliative approach is agreed and failure to undertake a comprehensive assessment at this time was a fundamental criticism of the Liverpool Care Pathway.
1.4The Recognising Dying form was launched in July 2014 by the Derbyshire Alliance for End of Life Care and is part of an End of Life care Toolkit to support the care of patients in the terminal phase of their lives. National guidance within the One chance to get it right document have designated the form for completion by a doctor only, yet the majority of medical care provided within Community Hospitals is provided by Advanced Nurse Practitioners, and access to a doctor is often restricted. This raises concerns that failure to complete the Recognising Dying form may delay the initiation of good end of life care. The view of the Nursing and Midwifery Council was sought to ascertain whether it was acceptable for Advanced Nurse Practitioners to undertake this assessment. The NMC advise that such decisions should not be made by a nurse, no matter how senior or experienced.
2.Purpose of Guidance
2.1This guidance sets out an appropriate process for reviewing patients at end of life, completion of the Recognising Dying form and initiation of quality end of life care.
3.Priorities of Care
3.1.1Patients Who Deteriorate Unexpectedly
In Community Hospitals where access to a doctor is restricted, a medical review must be undertaken by a doctor for all patients who experience a potentially life-threatening and unexpected deterioration. For example, a patient undergoing rehabilitation who becomes medically unstable or acutely unwell will trigger a review by the Advanced Nurse Practitioner or out of hours service. This is likely to result in an urgent transfer of the patient to a medical assessment unit for a medical review to exclude reversible causes.
Completion of the Recognising Dying form is unnecessary unless the patient declines transfer to an acute hospital or an out of hours doctor decides that a transfer is not indicated or is not in the best interests of the patient. The Recognising Dying form should be completed by the doctor undertaking the medical review if appropriate to do so.
3.1.2Patients Who are Admitted for End of Life Care
Patients who are admitted for end of life care within a Community Hospital have already been recognised as approaching the end of their lives by a Senior Doctor at the Acute Trust or by their GP and therefore their deterioration is neither unexpected nor potentially reversible. Some of these patients may die within a few hours or days of admission to a Community Hospital, but the majoritywill follow a recognisable lingering trajectory of dying which may last considerably longer than a few days.
These patients will have a clear audit trail of their illness trajectory recorded within the medical notes describing their diagnosis, treatment, decision to adopt a palliative approach and discussions with the patient and/or family in previous care settings. This audit trail should be summarised on admission to the Community Hospital and all subsequent discussions with the patient and significant others regarding any end of life care decisions should be documented in the medical notes. The Recognising Dying form should be completed by the responsible doctor during the next routine visit. ?
3.1.3Patients Who have Not Been Admitted for End of Life Care
Some patients with frailty or end-stage disease are referred to a Community Hospital for rehabilitation but are actually entering a terminal phase of their lives. These patients may fail to respond to treatments, for example oral antibiotics for a chest infection, and it is important that the possibility that the patient is dying or may die is recognised and documented at an early stage in order to elicit end of life care preferences , establish ceilings of care and to prepare both the patient and family for an outcome that may not have been anticipated on admission. This assessment should be recorded by a doctor on the Recognising Dying form or in the medical notes during ward rounds.
Often the ward nurses are the first to recognise that a patient is approaching the end of their life and this suspicion should trigger a routine medical review in order to exclude reversible causes for the deterioration by a doctor or an Advanced Nurse Practitioner. Reversible causes may include the effects of medications, metabolic disturbances or infection. If time is critical it may not be practicable for the responsible doctor to visit these patients in person prior to the initiation of end of life care. In these circumstances the Advanced Nurse Practitioner must consult the responsible doctor by telephone and document the consultation, plan of care and discussions with the patient and family.The Recognising Dying form should be completed by the doctor at the next available opportunity.
Sensitive communication is key to managing a good death. Ensure that the patient and significant others understand that they may be dying and outline any relevant treatment options. Discuss the patient with the team to ensure that the wider team is in agreement with your assessment. Document all conversations with patient, family or the professional team in the medical records.
Involve the dying person in decision relating to their care including preferred place of care, ceilings of care, resuscitation decisions and nutrition and hydration decisions. If the patient lacks mental capacity to make treatment decisions a best interests decision should be undertaken on their behalf in collaboration with those closest to them. Advance Decisions to Refuse Treatment and Lasting Power of Attorney must be respected when the patient lacks capacity.
Supporting families and significant others is an important role of the Advanced Nurse Practitioner. Keep those who care for the patient informed and involved in any decision-making. Inform the patient and those important to them the name of the doctor who has responsibility for their treatment and care.
3.5Plan and Do
Develop an individualised plan of care and treatment to meet the dying person’s own needs and wishes, and document this so that consistent information is shared with those involved in the person’s care and is available when needed.
Address actual and potential problems pertaining to symptom control, including the relief of pain, nausea, agitation, secretions and breathlessness.
Address issues relating to the person’s physical, emotional, psychological, social, spiritual, cultural and religious needs.
Support the person to eat and drink as long as they wish to do so and ensure that decisions to withdraw/withhold artificial nutrition and hydration are explicit and documented.
Refer to specialist palliative care as appropriate or ring for advice as necessary.
4.Roles and Responsibilities
- Review the dying patient regularly as part of routine ward rounds
- Complete a Recognising Dying form for all patients admitted to the Community hospital for end of life care and for those patients who are admitted for assessment or rehabilitation but who subsequently deteriorate
- Undertake an assessment to ensure that reversible causes of deterioration have been excluded
- Complete the death certificate
4.2The Advanced Nurse Practitioner will:
- Liaise with the ward team regarding recognition of dying patients
- Undertake a preliminary assessment of patients who may be dying
- Prescribe anticipatory medications for symptom control
- Communicate with the patient and their family
- Ascertain care preferences if advance care planning has taken place
- Sensitively discuss resuscitation decisions and ceilings of care
- Discontinue unnecessary interventions that may include investigations, observations and medications
- Review the patient daily or more frequently if required
- Ensure that a doctor has completed an assessment of the patient and is in agreement that the patient is dying
4.3The Ward Teamwill:
- Make the Advanced Nurse Practitioner or doctor aware that a patient may be dying
- Communicate sensitively with the family and support their care needs as required
- Implement an individualised end of life care plan as directed by the doctor or Advanced Nurse Practitioner
- Review the patient regularly including the evaluation of prescribed medications
- Report changes in condition to the Advanced Nurse Practitioner or doctor and request patient review as appropriate
Training events will be provided by the End of Life Care Facilitators in partnership with the Derbyshire Alliance for the Dying Person.
- Senior nurses are fundamental in the care of dying patients in both hospital and community and are not prevented from recognising someone is dying and acting accordingly (e.g. to prescribe medication) by the absence of a Recognising Dying form.
- It is the responsibility of the doctor to complete the Recognising Dying Form at the earliest opportunity
- Dying patients should be reviewed regularly by the doctor as part of every Ward Round
- Teams must be able to demonstratethrough clear concise documentationthat they have communicated clearly to a patient and family what is believed to be happening and that the individual’s priorities for care have been taken into account.,
- The documents contained within the End of Life Tool Kit are recommended to teams through the county as possible ways to deliver care. A one-size fits all approach is not advocated: common sense must prevail
Algorithm for the Recognition of the Dying Patient within Community Hospitals
Recognising Dying in Community Hospitals v1 (Andy Cole, 04/03/2015 10:26:00)