Care Pathway - NHS Wales Wales... · All Wales Care Pathway for the Last Days of ... The Care Pathway is intended as a guide in providing care for the patient and their family

ICP Version 1 June 2010: Review May 2011 Page 1 of 14

Care Pathway

The information contained in this integrated care pathway is confidential and it is the responsibility of all members of staff to ensure that it remains so. The information

contained within should only be accessed on a strict „need-to-know‟ basis.

All Wales Care Pathway for the Last Days of Life (Based on the Liverpool Royal United Hospitals’ ICP for the dying patient*) Incorporating Changing Gear**

The Care Pathway is intended as a guide in providing care for the patient and their family in the last days of life.

As a multi-disciplinary document it replaces the current medical and nursing notes during this period of care. These guidelines are based on best accepted practice. Each professional should exercise their professional judgment when using this guidance. INSTRUCTIONS FOR USE 1. Medical & Nursing Assessments should be completed while the patient care is guided by

the Pathway. 2. When care pathway is being used all risk assessments together with pressure area and

personal care continue as before 3. Ongoing Assessment (nursing) should be completed every 4 hours or at each visit using

a new sheet each day. 4. Variance occurs if the Pathway is not followed as expected. Any variance should be

recorded on the variance sheet, If a box in italics is ticked, explain action/inaction on variance sheet. N.B. A variance is not wrong, but it is important to record it, to help with quality monitoring and audit.

5. Multi-disciplinary progress notes allow scope to record anything not covered by the Pathway. These should record communication with the patient and family.

* LCP Ellershaw J., Foster A., Murphy D., et al. (1997). Developing an Integrated Care Pathway For Dying Patients. ‘European Journal of Palliative Care’ 4 page 203-207. ** Changing Gear updated November 2006 www.ncpc.org.uk

Contact Details


Medical Assessment

DIAGNOSIS

Criteria for ICP Do Not use the care pathway for the last days of life unless these two are fulfilled

1 Have reversible causes of deterioration been excluded? Yes No

2 Does the team agree that the patient is dying Yes No

GP/Consultant If an in-patient has GP been informed of situation? Yes No

Would the patient / family like to talk to somebody about tissue/organ donation ? Yes No

If yes phone: North Wales 0800 4320559

South Wales 07659 591889

GOAL 1 PLACE OF CARE

Is the patient in his / her currently preferred place of care Yes No Don’t Know

GOAL 2 CURRENT MEDICATION ASSESSED AND NON ESSENTIALS DISCONTINUED

Appropriate oral drugs converted to subcutaneous route via syringe driver

(if required) Yes No

GOAL 3 HYDRATION

In some patients or following discussion with relatives it may be appropriate to use s/c fluids

Parenteral fluids required Yes No

GOAL 4 PRN WRITTEN UP (AS LIST BELOW) – REFER TO GUIDELINES

Pain - Diamorphine Yes No

N&V - Cyclizine Yes No

Agitation - Midazolam Yes No

Respiratory Tract Secretions - Hyoscine Hydrobromide Yes No

GOAL 5 DISCONTINUE INAPPROPRIATE INTERVENTIONS

Blood Tests Yes No Not applicable

Treatments that are failing to achieve therapeutic goal Yes No

Implantable Cardiac Defibrillator deactivated Yes No Not applicable

DNACPR written in Medical notes/form completed Yes No

DNACPR discussed with relatives Yes No Not applicable

Doctor’s Signature __________________________ Date ______________________

Print Name ______________________________________

Name: Date of Birth: Address: NHS Number:

Date………………………

Yellow


Nursing Assessment

GOAL 6 COMFORT MEASURES

(Consider the environment: comfort, safety, temperature, ventilation).

Recording of Blood Pressure discontinued Yes No

Pressure areas assessed Yes No

Assessed need for - special mattress Yes No

- single room Yes No Not Applicable

Assessed condition of mouth Yes No

Action taken on any of above assessments:

GOAL 7 COMMUNICATION

Preferred language: Barriers to communication:

GOAL 8 IDENTIFY AND ADDRESS PATIENT‟S FEARS AND ANXIETIES

Patient recognises that they are dying Yes No Don’t Know Fears identified (specify):

GOAL 9 MOBILITY/SAFETY

Supervision required Yes No

Assessed for bed aids / sliding sheet. Yes No

GOAL 10 MICTURITION DIFFICULTIES

Urinary catheter if in retention. Yes No

Urinary catheter or pads, if general weakness creates incontinence

GOAL 11 HAZARDS IDENTIFIED

Infection/ radiation control referral if appropriate Yes No Not Applicable

GOAL 12 SPIRITUAL/RELIGIOUS/CULTURAL REQUIREMENTS

Religion identified (please specify): …………………………………………………………….. If appropriate – contact made with relevant minister? Yes No Contact name: Tel. no: Religious/cultural needs identified & action taken: Yes No Not Applicable


Green

Date………………………


GOAL 13 BEREAVEMENT PLANNING/FAMILY CARE

Family recognise that patient is dying Yes No Don’t Know

Care discussed with relative

and recorded on MDT sheet Yes No

Anxieties or Fears identified, please state:

GOAL 14 DETAILS OF HOW TO INFORM FAMILY/ OTHERS OF IMPENDING DEATH

At anytime Not at night Contact name: Relationship to patient: Telephone No: Second contact name and number:

GOAL 15 FAMILY GIVEN LOCAL INFORMATION

Family shown local facilities Yes No - over-night stay, availability of food and drinks, location of phones, washing facilities, parking arrangements etc. Family needs (please state): ……………………………………………………………

Nurse’s signature ___________________________ Date _______________ Print Name _______________________________________________

Green


Date………………………


Regular Symptom Assessment & Review CODES (to enter in columns) A – goal achieved, V – goal not achieved record on variance sheet, N/A – not applicable

DATE & TIME

PATIENT IS FREE OF:

GOAL 16 PAIN

GOAL 17 AGITATION

GOAL 18 “RATTLING” SECRETIONS

GOAL 19 NAUSEA / VOMITING

GOAL 20 MOUTH CARE

Mouth care carried out & mouth is clean

GOAL 21 MEDICATION

Medications reviewed & delivered safely.

GOAL 22 INTERVENTIONS

Inappropriate interventions discontinued

GOAL 23 COMMUNICATION – PATIENT

Patient aware of situation as appropriate.

GOAL 24 COMMUNICATION – FAMILY/ OTHERS

Family/others prepared for patient‟s death.

GOAL 25 OTHER SYMPTOMS

Other distressing symptoms controlled

Symptom Goal Symptom Goal

Print Name & sign each observation


Date………………………

Blue


CARE AFTER DEATH

CARE AFTER DEATH

Death Verification

Date of death ____________________________ Time of death ______________ Signature of verifier _____________________ Date __________ Time ________ Print Name _____________________

Death Certification

Date of death ____________________________ Time of death ______________ Signature of certifier _____________________ Date __________ Time ________ Print Name _____________________

GOAL 26 FAMILY To prepare, inform and support the patient‟s family /others, during final stages and immediately after death

Coroner needs to be informed Yes No

Post mortem discussed Yes No

Mortuary viewing explained Yes No

Collection of belongings / valuables explained Yes No

Collection of certificate explained Yes No

Please tick one option

Patient for burial

Patient for cremation for cremation see below

Names of people present at time of death and relationship to the deceased:

GP informed of death by telephone or fax Yes No Date __/__/__ Time ___________ Health Professional Signature _______________________ Date _______________

Print Name ____________________________


Date………………………


Multi-disciplinary Progress Notes/Communication Sheet

Date Signature


Date………………………


Variance Page Gender………….. Age ……….. Diagnosis …………………………. No of Days on Pathway…………

Date Variance and explanation Action Taken Outcome Signature

Please state you locality ………………..

Please indicate setting: Community Hospital District Nurses Hospice Nursing Home DGH SPU Other / state…………………

Please return a photocopy of variance page/s to:- Ros Johnstone Project Manager at the Palliative Care Department Bodfan Eryri Hospital Caernarfon LL55 2YE


Date………………………


PRN Medication

Symptom Medication Dose Frequency Route Doctor‟s Signature

Date

Nausea/ Vomiting

Cyclizine Max 150mg/24hrs BNF

50mg 4hrly sc

Agitation Midazolam Max 30mg/24hrs BNF

5-10mg 2hrly sc

“Rattle” Hyoscine Hydrobromide Max 2.4mg/24hrs BNF

0.6mg 4hrly sc

Pain

See Guidelines

Others

PRN MEDICATION GIVEN

Date Time

Drug Dose Route Signature (Given by)

Signature (Checked by)


Date………………………


Guidelines for symptom management (Reference Dr I.N.Back Palliative Medicine Handbook http://book.pallcare.info

Syringe Drivers

Syringe drivers are not always necessary, but are extremely useful if the patient is: • nauseous or vomiting, or has poor oral absorption • unable to swallow or too weak for oral drugs • unconscious All the drugs in the guidelines are compatible in mixtures in a syringe driver. • Precipitation may occur with higher concentrations of cyclizine. • Water for injection to be used to dilute all drugs except levomepromazine (use 0.9% saline)

If the patient has renal impairment but is tolerating conventional analgesics use them, but consider dose

reduction. However if there are signs of opiate toxicity seek specialist palliative care or pharmacy advice.

Pain

Is the patient able to swallow medication? If yes: continue oral morphine SR + 1/6th dose for breakthrough pain If no: convert to a syringe driver with diamorphine (if converting to injected morphine, see section in italics below.) Use EITHER diamorphine or morphine as the parenteral drug. If converting to syringe driver with DIAMORPHINE: • Calculate 24h intake of morphine. • Divide total by 3 to get the equivalent dose of diamorphine CSCI over 24h. e.g. Patient on 60mg MST b.d. and had 3 doses of 20mg Oramorph

Total (60 x 2) + (3 x 20) =180mg morphine total in 24h Equivalent dose of diamorphine = 180/3 = 60mg/24h • Also needs breakthrough dose prescribing of 1/6th of syringe driver i.e. 10mg diamorphine 4-hourly SC PRN). If converting to syringe driver with MORPHINE: • Calculate 24h intake of morphine. • Divide total by 2 to get the equivalent dose of morphine CSCI over 24h. e.g. Patient on 60mg MST b.d. and had 3 doses of 20mg Ooramorph Total (60 x 2) + (3 x 20) =180mg morphine total in 24h Equivalent dose of morphine = 180/2 = 90mg/24h • Also needs breakthrough dose prescribing of 1/6th of syringe driver i.e. 15mg morphine 4-hourly SC PRN). If not previously on a strong opioid: • Bolus diamorphine or morphine 2.5-5mg SC • Syringe driver 10-20mg diamorphine or morphine CSCI over 24h • PRN medication - 2.5-5mg SC diamorphine or morphine 4-hourly To calculate subsequent dose of diamorphine or morphine: • Add the dose of diamorphine or morphine (i.e. syringe driver) plus all PRN doses given in the previous 24hrs. • Increase the syringe driver dosage accordingly. If pain persists, consider other causes of distress e.g. bone pain, neuropathic pain, anxiety, fear, full bladder. If

pain is not controlled, contact the local Palliative Care Team.

http://book.pallcare.info/


Fentanyl / Syringe Driver Always leave patch in situ when commencing a syringe driver

Fentanyl or buprenorphine transdermal patches can continue to be used in the last few days of life. However, it is not appropriate to alter the dose of the patches for any change in analgesic requirement, as there is a delay before the changes are clinically apparent.

Patient who is pain controlled Continue current medication i.e. fentanyl or buprenorphine patch, refreshing the patch every 72h (or as previously

managed). Use diamorphine sc for breakthrough pain.

Patient not pain controlled: Continue patch at its current dose. Add diamorphine CSCI via syringe driver. The dose in the syringe driver is calculated on previous 24h PRN

requirement converted to diamorphine equivalence e.g. patient on 75µg/h fentanyl patch who has required 2 doses of PRN oral morphine 45mg in the last 24h = 90mg oral morphine /24h.

diamorphine 30mg/24h CSCI Breakthrough doses should be 1/6

th of total 24h opioid use i.e. diamorphine + equivalence of patch e.g.

patient on 75µg/h fentanyl and 30mg/24h diamorphine CSCI patch equivalence (90mg/24h diamorphine) + diamorphine 30mg/24h CSCI : divided by 6 diamorphine 20mg sc breakthrough. Further increments in syringe driver dose should also take the patch equivalence into consideration e.g. if a patient on 75µg/h fentanyl patch and 30mg/24h diamorphine CSCI requires an increase in syringe driver dose Total equivalent diamorphine dose = 120mg/24h (as above) Increment of 25% = an additional 30mg/24h daimorphine New syringe driver dose = 30 + 30 = 60mg/24h diamorphine CSCI (and continue fentanyl patch 75µg/h) Further details available in Trust Formulary and BNF pages 12-15

Nausea and Vomiting • PRN medication on all treatment sheets: cyclizine 50mg SC bolus 4hrly • If nauseous or vomiting: cyclizine 150mg SC via syringe driver over 24h If patient has congestive heart failure use haloperidol rather than cyclizine • If problem persists: Add haloperidol 5mg to syringe driver over 24h, or Replace above drugs with levomepromazine 12.5mg over 24h Contact Palliative Care Team • If bowel obstruction present: contact Palliative Care Team.

Restlessness, Agitation, Anxiety

• All treatment sheets to have PRN midazolam 5-10mg SC • If patient is restless: Add 10mg midazolam to syringe driver over 24h Give up to 5mg midazolam 2-hourly PRN • The dosage in the syringe driver can be increased if needed in 50% increments to a maximum of 30mg in 24 hours. If patient remains restless, review for reversible causes, contact Palliative Care Team.

Noisy Breathing due to Respiratory Tract Secretions

• All treatment sheets to have hyoscine hydrobromide 0.4-0.6mg SC 4-hourly written up. • If symptom present give: hyoscine hydrobromide 0.4mg SC bolus Add hyoscine hydrobromide 1.2mg SC to syringe driver over 24h. • If symptoms persist: Increase hyoscine hydrobromide to 2.4mg (in 24h). Contact Specialist Palliative Care Team.

Out of Hours Specialist Telephone Help Line:

North Wales: 01978 316800

South East Wales: 02920 426000 South West Wales



OUT OF HOURS COMMUNICATION SHEET

Integrated Care Pathway For The Last Days Of Life

URGENT FOR IMMEDIATE ATTENTION OF DOCTOR

When ICP commenced, please complete and fax this sheet to relevant Out of Hours Service

FROM: SIGNATURE:

DESIGNATION: DATE AND TIME:

OOH Fax

Numbers

Central – 01745 534220 East – 01244 834971 West – 01248 370138

PATIENT DETAILS

Name:

D.O.B

Address:

Telephone No:

Next of Kin/Main Carer: Address: Telephone No:

PATIENT‟S OWN GP DETAILS

Name: Practice Name: Telephone No:

Date of Notification to Out of Hours Service: Do you wish to be contacted concerning care?

Yes No

OTHER SERVICES INVOLVED: - Please indicate

District Nurses: Marie Curie Nursing Service: Macmillan Specialist Palliative Care Team:

DIAGNOSIS AND RELEVANT HISTORY

Patient aware of Diagnosis Relatives aware of Diagnosis

Yes No Yes No

DRUGS PRESCRIBED FOR THIS PATIENT - Please Indicate

Diamorphine YES/NO

Hyoscine YES/NO

Midazolam YES/NO

Cyclizine YES/NO

Water for injection YES/NO

MANAGEMENT PLAN


LABEL

All-Wales DNACPR Form – COMMUNITY ADULT ONLY (over 18 years)

FO

RM

DN

A-C

PR-C

OM

M-v

1 J

ul 2009

Full name of patient …………………………………………………………………………………………………………………………………………………………

Patient NHS/Hospital No …………………………………………………………. Date of Birth …………………………………………………………

Address ………………………………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………. Postcode ……………………………………………………………….

A decision has been taken that Cardio-Pulmonary Resuscitation (CPR) is NOT appropriate for the above patient. All other appropriate treatment and care should be provided.

Any discussion around this decision (with patients, relatives, team members etc) should be clearly documented in patient’s notes.

Please tick ONE of the 3 boxes below. The patient is being cared for with the Last Days of Life care pathway

1 and CPR is inappropriate.

CPR has been discussed with the patient/next of kin/proxy2

The patient/next of kin/proxy is aware that the patient is imminently dying from an irreversible disease, and discussion of CPR is not considered appropriate

CPR is unlikely to be successful or is likely to be followed by a length and quality of life which would not be in the best interests of the patient.3

This has been discussed and agreed with the patient's next of kin/proxy2

The patient lacks capacity to make this decision due to an irreversible condition4

All reasonable attempts have been made to exclude communication barriers to discussion with the patient

The decision is not contrary to any known advance decision of the patient

CPR is not in accord with the known or expressed sustained wishes of the patient.5

This has been discussed with the patient, who is mentally competent

This has been documented in a valid applicable advance decision to refuse treatment, which I have read6

Where is the advance decision document kept? ……………………………………………………………………………………………………

If discussion has taken place with family or proxy, please tick and give details:

Name of relative or proxy DELETE AS APPROPRIATE Next of kin / LPA / CAD / IMCA2

Contact details

Signature of senior Health Care Professional

Date:

Print full name Time:

Address Tel No:

DO NOT ATTEMPT CPR RESUSCITATION (DNACPR)

1 CARE PATHWAY

2 BEST-INTERESTS DECISION

3 ADVANCE DECISION BY PATIENT

Review of DNACPR Status

DNACPR status should be reviewed when there is any significant change in the patient's circumstances.

If the DNACPR decision is cancelled, please:

strike through both sides of this form

file this form in the patient's health record

inform other care providers

Notes 1 The Last Days of Life care pathway is also known as the All-Wales Integrated Care Pathway for the Dying, and other

similar names. Discussion with the patient/next of kin/LPA/CAD/IMCA is not compulsory in this situation, but one of the options must be ticked.

2 Proxy means one of the following: LPA = Lasting Power of Attorney; IMCA = Independent Medical Capacity Advocate; CAD = Court Appointed Deputy. Delete as appropriate.

3 A best-interest decision made on behalf of a patient must meet all the conditions of the Mental Capacity Act 2005. In a ‘best-interest’ decision, all 4 of the boxes must be ticked. You should also record details of discussions in the patient’s notes.

4 Please refer to the Mental Capacity Act 2005 for conditions when determining a 'best-interest' decision for a patient who lacks capacity.

5 Discussion with the next of kin is not compulsory in this situation, but is strongly advised (with the patient’s permission). One of the 2 options must be ticked.

6 Please refer to the Mental Capacity Act 2005 for details of what constitutes a "valid applicable advance decision".

COMMUNITY NURSING SERVICE (for use in the patient’s home)

Controlled & Other Prescribed Drugs for use in Syringe Drivers

Date Drug Dose Freq Route Doctor’s Signature Disc

Date

Name:

Date of Birth:

Address:

NHS Number:

Date………………………

COMMUNITY NURSING SERVICE (for use in the patient’s home) “Review Daily” Controlled & Other Prescribed Drugs for use in Syringe Drivers / Bolus

Date Time Drug Dose

Administered

Checked

By

Administered

By

Breakthrough Pain

Date Time Drug Dose

Administered

Checked

By

Administered

By

Date………………………

Name:

Date of Birth:

Address:

NHS Number:

SYRINGE DRIVER CHECK CHART HOSPITAL/WARD (IF APPLICABLE) Please complete or Affix Addressograph

EQUIPMENT MODEL

E.G. MCKINLEY T34

D NUMBER: D.O.B:

SURNAME:

EM NUMBER (Separate Form Required Per Driver)

FORENAME:

ADDRESS:

Equipment Within Test Date? YES/NO Equipment out of Test date must not be used and must be reported to Electronics Help Desk – Tel 4286/4197/4792

Is Spare Battery Available? YES/NO

TEL. NO:

HAS THE CORRECT SYRINGE BEEN IDENTIFIED BY THE SYRINGE DRIVER ? YES / NO

Please note if incorrect syringe size / brand displayed - remove the syringe from the driver and ensure that it is reinserted correctly until the correct size and brand is displayed

Date

Time

set up or

checked

(24

HOUR

CLOCK)

Prime New Line

YES/NO

Needle Site

1= Clean

2= Red

3=Inflamed

Connections

Secure

Correct

syringe

identified by

syringe

driver

YES/NO

Infusion rate

setting

(Give reason for

any change to

rate)

Total

volume

infused at

each

check

Volume

left in

syringe

Is the solution

clear

(and not

crystallised)

?

Yes/No

KEY

PAD

LOCK

ON

YES/NO

Battery %

(> 40% for community)

Display Screen

Reading / Pump

Delivering

Is the light

flashing

YES/NO

Name and

signature of

Registered

Nurse

Checked by

Name &

Signature

FREQUENCY OF CHECKS-

IN HOSPITAL:- Checks should be made after 30 minutes of starting the infusion (to see if the driver is working) and then 4 hourly.

IN THE COMMUNITY:- Check on each visit

REFERENCES:-

Infusion Systems- Medical Devices Agency Bulletin, March 2003,

Standards for Infusion Therapy Royal College of Nursing, November 2005

McKinley T34 Syringe Driver Guidelines. Graseby MS26 Syringe Driver Guidelines. North West Wales NHS Trust. c260(a) Policy and Guidelines for Health Care Assistants witnessing the preparation and administration of controlled drugs in a syringe driver in a Community

Hospital

Date

Time

set up or

checked

(24

HOUR

CLOCK)

Prime New Line

YES/NO

Needle Site 1= Clean

2= Red

3=Inflamed

Connections

Secure

Correct

syringe

identified by

syringe

driver

YES/NO

Infusion rate

setting

(Give reason for

any change to

rate)

Total

volume

infused at

each

check

Volume

left in

syringe

Is the solution

clear

(and not

crystallised)

?

Yes/No

KEY

PAD

LOCK

ON

YES/NO

Battery %

(> 40% for community)

Display Screen

Reading / Pump

Delivering

Is the light

flashing

YES/NO

Name and

signature of

Registered

Nurse

Checked by

Name &

Signature

This Form will be used in conjunction with the Medication Chart and Daily Intake & Output Chart A separate form is required for each line Completed forms will be stored in the Nursing Section of the Patients Medical Records

Documents

Care Pathway - NHS Wales Wales... · All Wales Care Pathway for the Last Days of ... The Care Pathway is intended as a guide in providing care for the patient and their family