Trust Procedures · V1.2 Updated section 4 – reference made to the Mental Capacity Act Procedure if a patient lacks capacity. Section 7.1 update to include reference regarding children

Trust Procedures

Guidance for the management of palliative care in hospital during the COVID-19

pandemic.

Version 1.3

This Procedure applies Trust-wide

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Document control page

Procedure number V1.3 Name of Procedure Guidance for the management of palliative care in hospital

during the COVID-19 pandemic. Name of linked Policy End of Life Care

Care and Communication SOP Accountable Director Joanne Hiley Author with contact details Maresa Johnson

[email protected] Status (draft/ ratified) DRAFT Ratifying Committee/ date Clinical Ethical Reference Group (CERG) 20/04/2020

V1.1 Clinical Ethical Reference Group (CERG) 28/05/2020 V1.2 Clinical Ethical Reference Group (CERG) 20/06/2020 V1.3 Clinical Ethical Reference Group (CERG) 08/07/2020

Review date 20/04/2021 Brief description of changes following review

Specific to COVID 19

Equality Impact Assessment The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This Procedure has been Equality Impact Assessed and does not discriminate.

Version control Version number

Development Timeline Date

V1 New Procedure 14 April 2020 V1.1 Trust received updated NHS guidance document 13 May.

Clinical guide for supporting compassionate visiting arrangements for those receiving end of life care Publication approval reference: 001559. Section 7 Visiting arrangements updated in line with guidance. Appendix 6 added Advice and support to visitors at end of life. Requirement to self-isolate for 14 days following visiting removed.

21 May 2020

V1.2 Updated section 4 – reference made to the Mental Capacity Act Procedure if a patient lacks capacity. Section 7.1 update to include reference regarding children visiting dying patients

18 June 2020

V1.3 Section 7.1 updated to state follow trust visiting guidance. Appendix 6 Visiting guidance for patient with and without COVID-19 removed

06 July 2020

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Contents Page

Page 1 Introduction 3 Background: COVID-19 4 2 Procedure details 4 3 Goals of care 5 4 Treatment escalation planning 5 5 Symptom management 6 6 Care of the dying patient 6 7 Practical consideration to support visiting at end of life during

the coronavirus pandemic. 7

7.1 Visiting Patients 8 8 At the time of death 8 9 Collecting property/ mementoes 9 10 Last Officers and Physical Care After Death – Nursing 9 11 Coroner Referrals, Medical Certificate of the Cause of Death

(MCCD), and Cremation Form. 9

12 Monitoring of compliance with this procedure 11 13 References Associated documents 11 Appendices Appendix 1 Important considerations for care immediately before and

after death COVID-19 Outbreak 12

Appendix 2 Procedure Following the Death of a Patient – inpatient units 13 Appendix 3 Registering a Death 17 Appendix 4 Talking to relatives 20 Appendix 5 Delivering the news of a death by telephone 21 Appendix 6 Advice and support to visitors at end of life 22 Appendix 7 Prescribing Guidance for Inpatient COVID-19 and End of Life 23 Appendix 8 Inpatient Care and Communication Record 29

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1. Introduction Background: COVID-19 Coronaviruses are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. They have also been detected in blood, faeces and urine and, under certain circumstances, airborne transmission is thought to have occurred from aerosolised respiratory secretions and faecal material. As coronaviruses have a lipid envelope, a wide range of disinfectants are effective. PPE and good infection prevention and control precautions are effective at minimising risk but can never eliminate it. As COVID-19 has only been recently identified, there is currently limited information about the precise routes of transmission. Effective infection prevention and control measures, including transmission-based precautions (airborne, droplet and contact precautions) with the recommended PPE are essential to minimise these risks. Appropriate cleaning and decontamination of the environment is also essential in preventing the spread of this virus. 2. Procedure details As clinicians, we all have responsibilities in relation to coronavirus and we should seek and act on national and local guidelines. We have a specific responsibility to institute best practice palliative care for all patients who require this, either with pre-existing palliative care needs or because of coronavirus infection. We may need to work outside our specific areas of training and expertise, and the General Medical Council has already indicated its support for this in the exceptional circumstances we may face. This guidance is aimed at all professionals looking after patients with coronavirus, and their families, in the hospital setting. This guidance does not replace evidence based local guidelines for palliative care. It is intended to support practice in safely managing, visiting and delivering Care after Death in the case of patients with confirmed or suspected COVID-19, and to unify processes across the Trust. This procedure is subject to change following updated guidance.

https://www.gmc-uk.org/news/news-archive/how-we-will-continue-to-regulate-in-light-of-novel-coronavirus

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3. Goals of care The treatment of patients suffering from coronavirus may be orientated towards: • Supportive measures – for example, provision of fluids and/or oxygen. • Targeted treatment – for example, provision of antibiotics to treat pneumonia. • Organ support – for example, ventilator support, renal replacement therapy, etc. These are aimed at preserving and prolonging life. It is important to remember that most people with coronavirus will survive and recover. For those who are dying as a consequence of coronavirus and/or who do not wish to have active or invasive treatments, the switch in focus to high quality, compassionate, palliative care at the end of their life is equally important. 4. Treatment escalation planning In the context of the coronavirus pandemic, decisions about further treatment escalation or shifting the focus to palliative care will need to take place rapidly. If the patient lacks capacity with regard to decisions about their care and treatment please refer to the Trust Mental Capacity Act Procedure On admission to hospital, assess all adults for frailty, irrespective of COVID-19 status.

• Use the Clinical Frailty Scale (CFS)

• Be aware of the limitations of using the CFS as the sole assessment of frailty.

• The CFS should not be used in younger people, people with stable long-term disabilities (for example, cerebral palsy), learning disabilities or autism. An individualised assessment is recommended in all cases where the CFS is not appropriate.

• Consider comorbidities and underlying health conditions in all cases.

• Record the frailty assessment in the patient's medical record.

Frailty scale

This algorithm may assist in decision making regarding ceilings of care by senior medical staff. Critical Care Admission Algorithm It may not be possible to have joint discussions involving the patient, those close to them and the clinicians because: • The patient may have become ill and deteriorated very quickly, so they may not be able to fully

participate in the decision-making. • The patient’s family and those closest to them may not be able to be present because of

hospital infection control procedures, or they may be in self-isolation or looking after family members who are ill.

http://nww.5boroughspartnership.nhs.uk/Documents/NWBH%20docs%202018/Dawn%20-%20policies/August%2018/MCA%20Procedure%20V4.0.pdf

https://www.nice.org.uk/guidance/ng159/resources

https://www.nice.org.uk/guidance/ng159/resources/clinical-frailty-scale-pdf-8712262765

https://www.nice.org.uk/guidance/ng159/resources/critical-care-admission-algorithm-pdf-8708948893

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Conversations with the patient’s family may well have to take place remotely. They are likely to be anxious and shocked by what has happened. These are not easy conversations to have but it is important that honest and timely conversations do take place. Senior clinicians should role model these conversations and support their teams to do so. Palliative care teams are skilled at these conversations and will do their best to support colleagues in doing so, but there will not be enough capacity for palliative care teams to undertake all conversations themselves. 5. Symptom management Even though many patients will survive and recover from coronavirus, managing their symptoms during this period remains important. This guidance assumes that a patient has received all appropriate supportive treatments and management of their comorbidities has been optimised. The good practice approach to symptom management in palliative care is as follows: • Correct the correctable, for example, give the patient antibiotics for a bacterial infection. • Non-drug approaches, especially in mild to moderate disease • Drug approaches These are the most common symptoms that may need to be addressed when a patient has COVID-19 particularly when they are reaching the end of life.

• breathlessness • cough • fever • delirium • Pain

See appendix 6 for prescribing guidance for the management of these symptoms when a patient has COVID-19 and is reaching the end of life. Prescribers are advised that some medications advised can be used to treat more than one symptom (for example morphine may be used to treat breathlessness and pain), careful consideration is advised when commencing and reviewing medications for symptom management at end of life. If further advice is needed, please see the contact information below for local specialist palliative care services below:

• Cheshire & Merseyside (Warrington, Halton, St Helens & Knowsley localities) 24 Hour Specialist Palliative Care Advice line – 0844 225 0677

• Wigan & Leigh Hospice (Wigan/Atherleigh Park) 24 Hour Specialist Palliative Care Advice line– 01942 525 566

6. Care of the dying patient Despite the challenging circumstances of the coronavirus pandemic it is paramount that dignity is maintained and not to lose sight of the important elements of holistic care of the dying person. This includes:

• Effective communication including clear decision-making. In order to be effective this may require accessing the translation and interpretation services for language and British Sign Language support. (This may be for the patient, family or carer etc).

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• Adequate pain and symptom management. • Maintain personal grooming and address hygiene needs • Opportunity to prepare for death, including emotional and spiritual support (chaplains and

faith leaders may play an important role here). The Chaplin for NWBH can be contacted directly, or via Switchboard for advice and support - Pam Lovatt;- 07384877802.

• Families may have a specific faith leader they wish to contact to provide support. • Further guidance and advice may be required, Please contact the Trust Chaplin who may

be able to answer the query or provide further information details and contact numbers. • Support for those close to the dying person, including the ability to keep in touch via phone

or virtual communication (for example, Skype, WhatsApp). Each ward has a iPad. • Sensitive conversations are required to be undertaken with the family/patient to ascertain

the patient’s wishes regarding the type of funeral they wish to have (burial or cremation) and which Funeral Director they wish to use. Note; if the patient is COVID positive and has requested a cremation, if they have an internal device check with the Funeral Director that their embalmer is able to remove it.

• It is important that if a patient is under a section of the Mental Health Act as they enter the end of life stage consideration MUST be given to its removal.

• During this time we need to consider the needs of the patient as a whole. For example, they may be in a same sex relationship, be a transgender patient, have a disability, be from a particular ethnicity/heritage, have a lack of faith, and these aspects need to be considered and respected. This can also impact on understanding who are significant people in that person’s life and how they are communicated with.

To ensure staff document all relevant information relating to the patient’s wishes and end of life treatment, once the patients enters this phase the Inpatient Care and Communication Record (CCR) will be completed by nursing and medical staff. See appendix 8 for the Inpatient Care and Communication Record that will be printed off and used. Once completed, the CCR will be uploaded on to RIO under the document title code CCR. 7. Practical considerations to support visiting at end of live during the coronavirus

pandemic.

• The dying person should be asked, where possible, if they would like to receive a visit from a loved one or faith leader.

• The number of visitors at the bedside is limited to one close family contact or somebody

important to the dying person. However, where it is possible to maintain social distancing throughout the visit, a second additional visitor could be permitted.

• Other people who are in attendance to support the needs of the patient should not be

counted as additional visitors.

• Anyone who is showing symptoms of coronavirus (a new continuous cough or a high temperature) should not visit, even if these symptoms are mild or intermittent, due to the risk they pose to others.

• Visitors are informed about what to expect when they see their loved one and practical

advice related to wearing personal protective equipment (PPE), handwashing and risks associated with the removal of gloves to hold hands.

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• Visitors must be made aware that good hand hygiene (handwashing) is needed to facilitate visiting. This is required to mitigate the risks to the visitor, other patients and staff.

• Continue to keep up-to-date with the latest infection prevention and control advice and

advice on the use of PPE from Public Health England. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

• Where possible, the dying person should be accommodated in a single room with

access to handwashing facilities.

• Preparing and supporting staff to support visiting at the end of life and manage the impact of this on their own wellbeing. Health Education England offers some practical learning around end of life communication https://portal.elfh.org.uk/Catalogue/Index?HierarchyId=0_45016_45128&programmeId=45016

7.1 Visiting patients Those wishing to visit people who are dying will need to make arrangements with the ward/Unit. Requests received from families for children to visit dying relatives need careful consideration to ensure not only the child’s best interests are paramount, but that if the request was to be approved the visit can be conducted in a safe and controlled manner. For further support and guidance in these situations please contact the Safeguarding Children Team.

• The visit is coordinated by ward team with support from the patients Responsible Consultant.

• Support for visitors can be provided across the whole team, including the hospital Chaplin. • PPE: Staff MUST ensure that family or friends who wish to visit loved ones at the end of

life follow the current trust visiting guidelines with regard to the donning and doffing of appropriate PPE. Staff MUST ensure that all appropriate documentation is completed. This guidance also applies to visiting faith leaders (including chaplains).

• See Appendix 6 for Advice and support to visitors at end of life – Emotional

If visiting is not possible there are alternatives that can be offered, such as telephone calls and video calls, such as Skype or Facetime. All discussions must be documented on RIO 8. At the time of death

Where coronavirus has been confirmed or, if the patient has been tested and no results are available yet, they will need to be treated as high risk when they die. Inform and Support Family and/ or Next of Kin. This may be done by a nurse or doctor on the clinical team. See appendix 4 and 5 for the following documents may be useful:

o Talking to Relatives: A Guide To Compassionate Phone Communication During Covid-19

o Delivering the News of a Death by Telephone

https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control


https://portal.elfh.org.uk/Catalogue/Index?HierarchyId=0_45016_45128&programmeId=45016

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• Remember to inform any person who has visited the deceased whilst they had Covid 19, whether in hospital or prior to admission, that they should self-isolate for 14 days

• If the relatives/ next of kin are present at the time of death, please give them the Bereavement Booklet with the additional Addendum to Bereavement Booklet: Covid 19 inserted (see Appendix 1)

• Inform the relatives/ next of kin of the following information regarding registering the death and collecting property/ mementoes:

Mementoes or keepsakes (for example, locks of hair, handprints, etc.) may be offered and taken at the time of care after death. These cannot be offered or undertaken at a later date. 9. Collecting property/ mementoes

• Any property/ mementoes will be cleaned if possible and placed in a sealed plastic bag before being placed in a property bag.

• Clothing, blankets, etc., should ideally be disposed of. If they must be returned to families they should be double bagged and securely tied and families informed of the risks.

• This property must be left within the sealed plastic bag for at least seven days. • If an appropriate member of the family/ next of kin is present at the time of death, this can

be given to them before they leave the ward • Otherwise, it will be kept on the ward and someone from the family who is not self-isolating

may come to the ward door, let someone know who they are, and a member of staff will retrieve the property bag for them.

• Any hospital linen should be placed in red alginate stitched bag and white outer bag

10. Last Officers and Physical Care After Death – Nursing

• Last Offices will be performed following medical verification of death. • Level 2 PPE must be worn when performing physical care after death in accordance with

the Trusts infection prevention guidance.

See Appendix 1 - Important considerations for care immediately before and after death See Appendix 2 – Flow chart and Explanation notes - Procedure Following the Death of a Patient – Inpatient Units See Appendix 3 – Registering the Death

11. Coroner Referrals, Medical Certificate of the Cause of Death (MCCD), and Cremation

Form. Deaths that are reportable to the Corner include. • Patients who are under state detention • The cause of death unknown • The cause of death unnatural See registered medical practitioners notification deaths regulations guidance An appropriate medical professional must complete the verification of death using PPE (in accordance with Trust guidelines) and maintaining infection control measures. This MUST be completed prior to the Funeral Director removing the body from the ward and documented accordingly on RIO.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/851973/registered-medical-practitioners-notification-deaths-regulations-guidance-print.pdf

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If the patient’s death does not need to be reported to the Coroner, a doctor then;-

• Completes the Medical Certificate of Cause of Death (MCCD) certificate as soon as possible.

• The MCCD is then given to the family so that the death can be register at the Register Office for the area in which the death has occurred.

NOTE;- The death must be registered within five working days. See Appendix 3 COVID-19 is an acceptable direct or underlying cause of death for the purposes of completing the MCCD. It is not a reason on its own to refer a death to a Coroner under the Coroners and Justice Act 2009. That COVID-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a Coroner is required by virtue of its notifiable status. Details of the local Registration District Offices can be sourced via the internet or local directories for information and all visits are by appointment only. The address and telephone numbers for the St Helens, Whiston and Wigan Registrars are located in Appendix 3. Coordination of support for the bereaved family and those close to the patient should be managed, signposting them to locally and nationally available support services, including those provided by the voluntary sector. If the patient’s death is reportable to the Coroner, the Police MUST be contacted. The Medical trainee will verify death. The body and Scene MUST not be disturbed until attendance and approval is given by the Police to do so. The police will arrange for the coroners’ removal service to attend, the body will be transferred to the community mortuary. A Medical Certificate of Cause of Death MUST NOT be issued until approval is given by the Coroner. What to do if the patient/family wish is for cremation following death. If the patient’s death does not need to be reported to the Coroner the patients Responsible Consultant/Medical trainee will.

• Complete the MCCD • in order for a body to be cremated an application still has to be made • only Form 4 needs to be completed by the doctor issuing the MCCD (Cremation forms are

kept with the MCCD book). • the body has still to be seen after death by the doctor issuing the MCCD • there is no requirement for a confirmatory certificate – Form 5 • there is still a requirement that no cremation can take place without the Cremation referee

issuing Form 10 (this completed by an external doctor and arranged by the Funeral Director)

• the provisions relating to the issue of Form 6 by the Coroner still applies and a cremation take place if this is issued

The cremation guidance has been revised to reflect the temporary changes to the Cremation (England and Wales) Regulations 2008 provided for in the Coronavirus Act 2020 which came into

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force on 26th March 2020. The amended Regulations and revised guidance will be in force until further notice.

• The doctor completing the Cremation form must read and understand the current guidance cremation forms and guidance.

• The cremation form once completed is either given to the Funeral Director when they collect the body or it can be scanned and sent to the Funeral Director.

If the patient’s death is reportable to the Coroner

• A Medical Certificate of Cause of Death MUST NOT be issued until approval is given by the Coroner.

• A cremation form MUST NOT be completed until approval is given by the Coroner. 12. Monitoring of compliance with this procedure

Minimum requirements to be monitored

Process for monitoring e.g. audit

Responsible individual, group or committee

Frequency of monitoring

Responsible individual, group or committee for review of results

Responsible individual, group or committee for development of action plan

Responsible individual, group or committee for monitoring of action plan

Staff are aware of the procedure on questioning

Monitoring tool

Resuscitation Steering Committee

Annual Resuscitation Officer

Resuscitation Steering Committee

QSSGG

References

• NHS Coronavirus Act – excess death provisions: information and guidance for medical practitioners; 31 March 2020

• https://www.gov.uk/government/collections/cremation-forms-and-guidance/

• https://www.gov.uk/government/publications/covid-19-guidance-for-care-of-the-deceased

• https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

• NHS Clinical guide for supporting compassionate visiting arrangements for those receiving care at the end of life. Publications approval reference 001559 13 May 2020

Associated documents

DNACPR FAQs.

uDNACPR

Resuscitation Policy

End of Life Care Policy

Mental Capacity Act Procedure

https://www.gov.uk/government/collections/cremation-forms-and-guidance

https://www.gov.uk/government/collections/cremation-forms-and-guidance

https://www.gov.uk/government/publications/covid-19-guidance-for-care-of-the-deceased



http://nww.5boroughspartnership.nhs.uk/policies-and-forms/policies-and-procedures/m-r/resuscitation-policy

http://nww.5boroughspartnership.nhs.uk/policies/Pages/End-of-Life-Care-Policy-.aspx

http://nww.5boroughspartnership.nhs.uk/Documents/NWBH%20docs%202018/Dawn%20-%20policies/August%2018/MCA%20Procedure%20V4.0.pdf

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Appendix 1

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Appendix 2

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Procedure for an expected death where the patient has suspected or confirmed COVID-19.

• Ensure, if appropriate, discussions regarding “do not attempt cardiopulmonary resuscitation” (DNACPR) are undertaken with patients/relatives, ideally in advance of an acute deterioration in the patients’ physical health. (There are booklets located with the uDNACPR forms).

• Ensure “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions are well documented and communicated.

• Ensure the uDNACPR form is completed correctly and communicated to all relevant staff. • Add a DNACPR alert into RIO. • Add DNACPR decision to patients care plan under End of Life Care. • Update wards physical health whiteboard if appropriate. • Ensure that the patient has appropriate End of Life Care medication prescribed. • Ensure the patients’ spiritual/emotional needs are explored. • Medical/nursing staff to undertake the sensitive conversations to find out the

patients/families wishes regarding funeral planning. Burial or cremation, which funeral Director they wish to use.

• If the patient is under a section ensure the section is removed as the patient moves into the end of life phase (if the section is not removed the patient’s death MUST be reported to the Coroner). See Appendix 2 - flow chart Procedure following the death of a patient – inpatient units.

• It is essential that Verification of Death has been completed and documented by a doctor prior to removal of the body by the Funeral Director. This can be completed by any grade of doctor.

• Any equipment used in the verification of Death process should be either disposed of or fully decontaminated.

• The doctor MUST also note any internal devices that the patient has. This information MUST be provided to the Funeral Director.

• Death from COVID-19 is considered a natural cause of death and therefore is not reportable to the Coroner, however there still maybe a reason to report the patient’s death to the Coroner Guidance-for-Staff-Responsible-for-Care-after-Death. If in doubt contact the Coroner’s Office for advice (contact details below).

• Contact funeral director (usually families’ choice) – inform Funeral Director suspected or confirmed COVID-19.

• Follow Trust guidance regarding the correct PPE to use when performing last offices/care after death. This is not classed as an aerosol generating procedure.

• Current Government advice states where the deceased was known or suspected to have been infected with COVID-19, there is no requirement for a body bag. Viewing, hygienic preparations, post-mortem and embalming are all permitted.

• Clearly identify the deceased person with a name band on their wrist or ankle (avoid toe tags). As a minimum this needs to identify their name, date of birth, ward and their NHS number.

• Remove jewellery (apart from the wedding ring) in the presence of another member of staff, unless specifically requested by the family to do otherwise, and document this

https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/10/Guidance-for-Staff-Responsible-for-Care-after-Death.pdf

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according to local policy. Be aware of religious ornaments that need to remain with the deceased. Secure any rings left on with minimal tape and document according to local policy.

• Use a surgical mask to cover the patient’s nose and mouth. • If the patient has dentures leave them in place. • Use a sheet to wrap the body and tape in place, • A Medical Certificate of Cause of Death will be written by the patients’ medical team –

Medical Death Certificate books are available at (Atherleigh Park Hospital – Golborne, Hollins Park Kingsley, Knowsley Resource and Recovery Centre – Rydal Ward)

• Cremation Forms (if required) are located with the Medical Death Certificate book on each site.

• Provide the family with support leaflets/booklets (if available) • Update RIO • A fast-track form must be used / attached to Datix to report the death of a confirmed

COVID-19 virus patient (NB: ensuring that patient has been swabbed and the results confirmed COVID-19 positive). This information must be reported on-line via the National COVID-19 Patient Notification System (CPNS)

- Deputy Director of Nursing and Governance

- Assistant Director of Nursing

- Head of Infection Prevention Control

- Head of Patient Safety and Risk

The fast-track form should clearly state that the death of the patient was from confirmed COVID-19 virus, to ensure that the regional validation and national reporting processes are accurate. See Incident Reporting and Investigation Procedure (Including serious incidents and near misses) procedure Appendix 2 for further guidance.

• Medical staff to Inform GP NOTE:-

If the cause of death is unknown/unnatural or the patient has died under state detention, a Medical Certificate of Cause of Death MUST NOT be issued staff must follow the guidance below;-

• The police must be notified • The police will attend, do not disturb the scene/body until the police have given approval. • The police will arrange the coroner removal service • The body will be moved to the community Mortuary. • The coroner will liaise with the patients Responsible Consultant regarding when the

Medical Certificate of Cause of Death can be completed. Death certification process

From NHS Improvement/England: Information cascaded to all doctors on 11 March 2020

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Prior to more detailed guidance being released for the death certification process in an emergency scenario, please follow these recommendations:

• Covid-19 is an acceptable direct or underlying cause of death for the purposes of completing the Medical Certificate of Cause of Death

• Covid-19 is not a reason on its own to refer a death to a coroner under the Coroners and Justice Act 2009.

• That Covid-19 is a notifiable disease under the Health Protection (Notification) Regulations 2010 does not mean referral to a coroner is required by virtue of its notifiable status.

• Where next of kin/informant is following self-isolation procedures, please arrange for an alternative informant who has not been in contact with the patient to collect the Medical Certificate Cause of Death and deliver to the registrar for registration purposes.

Coroners Contact numbers H M Coroner's Court Paderborn House Civic Centre Howell Croft North Bolton, BL1 1QY Main Tel : 01204 338799 [email protected]

Warrington Coroner’s Office East Annexe Town Hall Sankey Street Warrington WA1 1UH [email protected] Sefton Coroner’s Office Tel: 0151 777 3480

mailto:[email protected]

mailto:[email protected]

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Appendix 3

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Registering a Death St Helens Deaths Only The Registrar of Births, Deaths and Marriages St Helens Town Hall Victoria Square St Helens WA10 1HP 01744 456789 Whiston Deaths Only The Registrar of Births, Deaths and Marriages High Street Prescot L34 3LD 0151 443 5210 Leigh Deaths Only Leigh Register Office Wigan Council Wigan Life Centre The Wiend Wigan 01942 489003 Wigan Death Only (note information below on the Wigan website) Registration of Births Death and Marriages The Albert Halls, Victoria Square BL1 1RU 01204 331185

Death registrations (WIGAN ONLY)

The death of a loved one is a tragic event for all families and a stressful time.

Our aim is to provide as smooth and respectful a service as possible given the difficult circumstances.

If you need to register the death of someone who has passed away due to COVID-19, please do not make an appointment. Please ring us on 01204 331185 as soon as possible and we’ll be able to offer further advice and instructions.

In other circumstances death registrations will continue as normal, and please be aware deaths still need to be registered within five days from the date of death. Please book an appointment to register either online or by calling 01204 331185.

At this time only one person per registration will be able to attend the Register Office, irrespective of the cause of death.

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You will need to contact the hospital or your GP to arrange the collection of the medical cause of death certificate before you attend your appointment to register.

If the death has been referred to the coroner, you need to ensure the paperwork is ready before making your appointment. Please see our web pages for more information on the procedure for registering a death.

If you are an immediate relative and are unable to register due to the COVID-19 virus, please call 01204 331185 for advice regarding who may register on your behalf.

Thank you for your understanding

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Appendix 4

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Appendix 5

Curtesy of Warrington and Halton Teaching Hospital Palliative care team

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Appendix 6 Advice and support to visitors at end of life Emotional support

• Emotional support should be provided to visitors. This can take the form of:

- Preparing the visitor for what they will see when they arrive in the care setting. - Transport: visitors can be advised to consider being driven to the hospital by a member of

their household, if possible, to minimise the risk of exposure to others. They should avoid the use of public transport – especially after the visit. Visitors driven by a person close to them may welcome the support that person can offer once the visit has finished.

- What to do on arrival: and arrangements to escort the visitor to the ward/unit by the shortest possible route.

- Personal belongings: visitors should minimise the number of personal belongings they bring with them, eg bags, handbags, electronic devices.

- Clothing: the visitor should remove outer clothing, eg coat or jacket, roll up their sleeves and clean their hands before putting on PPE.

Tips: such as going to the toilet and having had a small drink before they don PPE helps to avoid the need to don and doff PPE more than once during the visit. • Explaining any limits to the length of time the visitor can stay. • Notifying the nurse caring for the person that a visitor has arrived and ensure that they know how to

use the call bell if they need anything or signal when they want to leave. • Providing comfort if the visitor is distressed, hold the persons hand(s), and provide further

appropriate emotional support away from the care setting. • Providing information to the visitor about what will happen next if their loved one has died. • Reassuring the visitor that self-isolation is not required following the visit as they have been

protected from the risk of transmission by using PPE and performing hand hygiene. • Signposting opportunities to prepare for death, including emotional and spiritual support (chaplains

and faith leaders may play an important role here).

Appendix 7. Prescribing Guidance for Inpatient COVID-19 and End of Life Developed in response to the COVID-19 pandemic Non-pharmacological

measures Oral/rectal/topical pharmacological measure

Injectable pharmacological measures

Breathlessness WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS Breathlessness (continued)

Optimise treatment of underlying causes of dyspnoea. Breathlessness is a subjective symptom and leads to anxiety, fear & distress. It is important to manage it well. Oxygen (no evidence of benefit in absence of hypoxaemia). NICE: When oxygen is available, consider a trial of oxygen therapy and assess whether breathlessness improves If eGFR less than 30ml/min: use midazolam 5mg every 24hours via CSCI If eGFR less than 30ml/min: use equivalent doses of oxycodone instead of morphine sulfate – seek advice Positioning (dependent on comfort: sit upright, legs uncrossed, let shoulders droop, keep head up, lean forward). • Support arms with pillows in ‘armchair’ configuration • Relaxation techniques • Teach ‘square’ breathing to those able to comply • Reduce room temperature & open windows as comfort allows • Cool face using cool flannel or cloth • Stroking along lung meridians • Do not use portable fans, during outbreak of Covid-19

Morphine to reduce the perception/sensation of Breathlessness: OPIOID NAÏVE (not currently taking opioids) • Morphine MR 5mg PO every 12hours regularly (titrate to maximum 30mg daily) • Morphine immediate release 2.5mg -5mg PO every 2- 4hours Prn ALREADY TAKING OPIOIDS • Morphine immediate release 5mg -10mg PO every 2- 4hours Prn - OR • One twelfth of 24 hour

dose for pain, whichever is greater

Add benzodiazepine if required:

In those unable to swallow: • Morphine 1mg-2mg SC every 2- 4hours (if not effective add midazolam 2.5mg SC every 4hours prn) In those in last days and hours of life: • Morphine 2.5mg-5mg SC every 4hours (if not effective add midazolam 2.5mg SC every 4hours prn) And consider • Morphine 10mg via CSCI (continuous subcutaneous injection – syringe driver) every 24hours (if not effective add midazolam 10mg via CSCI every 24hours)

24

WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS

• Lorazepam 500 micrograms-1mg PO/SL every 1-2hours Prn (Max 4mg/day (max 2mg/day in elderly)) OR • Diazepam 2mg-5mg every

8hours

Cough WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS

• Humidify room air (e.g. place damp towel on radiator) • Oral fluids • Suck cough drop/ hard sweets or a teaspoon of honey • Elevate head when sleeping • Avoid smoking

• Codeine linctus or tablets PO 15mg – 30mg every 4 hours as required up to 4 doses in 24 hours. Increase dose to 30mg - 60mg PO qds if necessary (Max 240mg in 24 hours) • Morphine immediate release PO 2.5mg – 5mg every 4hours prn Increase dose up to 5mg to 10mg every 4 hours PRN If the patient is already taking regular morphine- increase the regular dose by a third

If severe/unable to swallow or in last days of life • Morphine 2.5mg - 5mg SC every 4hours prn And consider • Morphine 10mg via CSCI every 24hours

• Reduce room temperature • Paracetamol PO/PR 500mg to 1g every 4

25

Pyrexia (temperature 37.8oC or greater) WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS

• Wear loose clothing • Cool face using cool flannel or cloth • Oral fluids (avoid alcohol) • Do not use portable fans, during outbreak of Covid-19

to 6 hours prn (Max qds/4g in 24hours) • Ibuprofen PO 200mg to 400mg every 8

hours prn (max tds/1.2g in 24hours) Please note guidance surrounding NSAIDs use in COVID 19 has changed as per Trust memo 16/04/20 For further information see: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0211-NSAIDs-RPS_14-April.pdf

Delirium and agitation WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS Delirium and agitation

Agitation may be caused by the anxiety associated with breathlessness, but don’t forget the important usual causes of full bladder, full rectum and full stomach. Delirium is an acute confusional state associated with hallucinations, agitation and drowsiness. Identify & exclude reversible causes. These need different management & consider hypoxaemia and manage according to environment and goals of care If eGFR less than 30ml/min: use midazolam 5mg every 24hours via CSCI • Ensure effective communication • Re-orientate to current environment • Provide reassurance • Avoid moving from one environment to another unless essential • Ensure adequate lighting and avoid shadows • Reduce unexpected noise to a minimum • Manage bowel and bladder care regularly

Agitation • Lorazepam tab 500 micrograms – 1mg PO/SL QDS (Max 4mg/day (max 2mg/day in elderly)) • Rectal diazepam 5mg -10mg PR every 12hours prn • Buccal Midazolam 5mg -10mg every 2hours prn Delirium (may be worsened by benzodiazepines) • Haloperidol tab/liq 500 micrograms – 1mg PO at night & every 2 hours prn (maximum daily dose 10mg

Agitation • Midazolam 2.5mg -5mg SC every 2 - 4hours prn And consider • Midazolam 10mg every 24hours via CSCI (titrate up to 30mg if needed) Delirium • Haloperidol 500 microgram – 1mg SC at bedtime and every 2hours prn Increase in increments of 500 microgram -1mg Higher doses (1.5mg -3mg) when severe distress And consider

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0211-NSAIDs-RPS_14-April.pdf



26

(continued) WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS

• Play calming, gentle and familiar (to patient!) music • Gentle hand massage

(5mg in elderly)) • Haloperidol 2.5mg to 10mg every 24hours via CSCI (+ midazolam 10mg helpful if anxiety)

Respiratory Tract Secretions WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS

Respiratory tract secretions are noisy & unpleasant for families/staff, do not distress patients, & do not usually need suction. If eGFR less than 30ml/min use glycopyrronium 100 microgram SC every 4hours prn • Positioning (various advice depending on position: sit upright, legs uncrossed, let shoulders droop, keep head up; lean forward) • Nurse in recovery position – fully over on side • Play music or television to obscure sound • Advise those important to the patient to take regular breaks from the bedside if present

• Hyoscine Hydrobromide 300 microgram tab (Kwells) PO/SL every 6hours • Hyoscine Hydrobromide 1.5mg Patch every 72hours (Scopoderm) (place behind ear)

• Glycopyrronium 200 micrograms SC every 4hours prn And consider • Glycopyrronium 600 - 1200 micrograms via CSCI every 24hours If ineffective or medicine not available consider • Hyoscine Hydrobromide 400micrograms SC every 4hours prn And consider • Hyoscine Hydrobromide 1200 -2400microgams via CSCI every 24hours

Pain Patients may experience pain due to existing co-morbidities but may also develop pain as a result of excessive coughing or immobility. Such symptoms should be addressed using existing approaches to pain management.

27

WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR ELDERLY PATIENTS Patient on no analgesics – mild pain Step 1: start regular paracetamol (usual dose 1g four times a day) dose reduction is advisable in old age, renal impairment, weight <50kg,etc Step 2: persistent or worsening pain: stop paracetamol if not helping pain start codeine 30mg - 60mg four times a day regularly prescribe prophylactic laxatives – ask about constipation Step 3: maximum paracetamol and codeine, persistent or worsening pain: stop paracetamol if not helping pain stop codeine commence strong opioid (e.g. oral morphine) continue prophylactic laxatives – ask about constipation Commencing strong opioids - Suggested starting doses

• opioid-naïve/frail/elderly: morphine 2.5mg - 5mg PO immediate release 4 hourly • previously using regular weak opioid (e.g. codeine 240mg/24h)

o morphine 5mg PO immediate release 4 hourly or MR 20mg - 30mg BD o frail/elderly: use lower starting dose of 2.5mg PO immediate release 4 hourly or MR 10mg - 15mg BD

• eGFR <30 ml/min - seek advice – use equivalent doses of oxycodone instead of morphine sulfate • if adjusting the dose of opioid, take prn doses into account • check that the opioid is effective before increasing the dose • increments should not exceed 33-50% every 24 hours • if pain control achieved on immediate release consider conversion to MR opioid (same 24-hour total dose) • seek specialist advice if analgesia titrated 3 times without achieving pain control / 3 or more prn doses per day / total daily

dose of oral morphine over 120mg / day unacceptable side effects When the oral route is not available

• if analgesic requirements are stable - consider transdermal patches (e.g. buprenorphine, fentanyl) • if analgesic requirements are unstable consider initiating subcutaneous opioids • morphine is recommended as the first line strong opioid for subcutaneous use for patients, except for patients who have

been taking oral oxycodone or those with severe renal impairment • if constant pain, prescribe morphine 4 hourly SC injections or as 24-hour continuous infusion via a syringe driver • conversion from oral to SC morphine: oral morphine 5mg is equivalent to subcutaneous morphine 2.5mg

28

• wide inter-individual variation exists and each patient should be assessed on an individual basis• prn doses of 1/10 to 1/6 of regular 24-hour opioid dose should be prescribed 2-4 hourly SC prn

Nausea and vomiting • Review the potential cause: cough, pain, urinary retention, constipation• Seek specialist advice in patients with severe heart failure (alternatives to cyclizine and levomepromazine may be needed)• WHERE DOSE ADJUSTMENT FOR ELDERLY IS NOT STATED – START AT LOWER END OF DOSE RANGE FOR

ELDERLY PATIENTS• Cyclizine PO 50mg bd to tds prn or if oral route unavailable cyclizine SC 25mg bd to tds prn• Consider if needed: cyclizine CSCI 150mg/24 hours• Alternatively:

o Prescribe levomepromazine SC 6.25mg every 4-6 hours prn up to a max. 25mg/24 hourso Consider if needed: levomepromazine CSCI 12mg - 25mg/24 hourso Levomepromazine has a long half life, a single dose may last up to 12 hours, be aware of sedation at higher doses

• Seek specialist advice if nausea and vomiting not controlled after 2 doses or patient already prescribed an antiemeticReferences

1. COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care. Northern Care Alliance NHS Group.Association for Palliative Medicine of Great Britain and Ireland. 22nd March 2020.

2. St. Helen’s and Knowsley Hospitals NHS Trust COVID-19 EOL guideline. March 2020.3. Palliative Care Formulary via www.medicinescomplete.com Accessed 5.4.204. Levomepromazine. Scottish Palliative Care Guidelines. Accessed 5.4.20.

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/levomepromazine.aspx5. NICE Guideline (NG163): COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community.

Accessed 6.4.20. https://www.nice.org.uk/guidance/ng163

http://www.medicinescomplete.com/

https://www.palliativecareguidelines.scot.nhs.uk/guidelines/medicine-information-sheets/levomepromazine.aspx

https://www.nice.org.uk/guidance/ng163

Care and Communication Record for

Name: ________________________

Prefers to be called: _____________

and those who are important to them.

NHS number

Consultant's name

Named nurse

Other specialist contact number(if applicable)

Originally developed and produced in partnership with Knowsley and St Helens CCGsCare and Communication Record Version 1 (in-hospital) April 2020 Review April 2023.

Appendix 8 – Care and Communication Record

CONTENTS

Introduction Page 3

Aide Memoire Page 4

Assessment

Patient Information - GREEN Page 5

Wishes and Preferences - PURPLE Page 6

Nursing assessment - GREEN Page 7

GP Assessment - BLUE Page 8

Plan of Care

Agreed Plan of Care - GREEN Page 9 & 10

Daily Care and Communication

Daily Care and Communication - PURPLE

Daily Symptom assessment - GREEN

Page 2

Care & Communication Record

This Care and Communication Record is intended to support the care of the

person who may be dying such that their wishes (and those who are important

to them) are understood and documented. It can be used when a doctor, nurse, and the person or those who are important to them agree that the person may

die in the next days or hours.

It includes an assessment of physical, emotional, practical and spiritual needs

and an individualised plan for care. There is an on-going record of care given and

communication between the person, those who are important to them and the

health and social care professionals supporting them.

For health professionals there is an Aide Memoire to act as a guide when

planning and delivering care for a person and those who are important to them.

A person and those that are important to them should expect that

communication will continue between themselves and professionals supporting

them (where possible and desired) and that any proposed changes to the care plan are discussed and agreed.

Assessment Section

BLUE: Doctors – where a doctor is in agreement that the person’s care should be supported by this Care and Communication Record they may document relevant

conversations and their medical assessment in the blue headed sections.

GREEN: Nurses – are asked to complete the green headed sections which relate to the assessment and agreed plan of care.

PURPLE: All – person and those who are important to them – may complete their wishes and preferences for End of Life Care with the support of Health and Social

Care Staff and should sign to consent to the agreed plan of care.


PURPLE: All – person and those who are important to them and all Health and Social Care staff may use the daily care and communication sheet to share

information about the on-going care of the person.

GREEN: Nurse – daily assessment to be completed at each visit, nursing intervention or 4 hourly in a care home.

Page 3

Recognise the possibility that the person

may die in the next hours or days and communicate this clearly but sensitively to the person if possible and those who are important to them.

A full assessment should be completed and consider revisable causes of decline which should be discussed with other members of the multi-disciplinary team and documented.

Communication is essential when caring

for a person who is dying and those who are important to them.

Communication should be timely, honest, open and sensitive, whilst maintaining privacy and dignity.

Take into account previously stated wishes and preferences, Advance Care Planning and documentation.

Support the person and those important to

them to make decisions about their care and treatments which should continue after the person has died.

Ensure the person and those important to them know who is responsible for care and how to contact them.

Provide them with information according to their needs and ensure they are supported both emotionally and practically.

Explore spiritual, religious and cultural needs, include them in the care plan and support as much as possible.

Involve the person and those identified as

important to them in decisions about their care and treatments as much as they wish.

If the person lacks capacity (take into account the Mental Capacity Act) to make decisions consider involving other professionals and/or IMCA.

On-going medical support should continue dur-

ing this period by the GP and if involved Spe-

cialist Palliative care.

Plan of care which should take into account a person’s: physical,

psychological, social, spiritual needs and preferences.

Medication should be prescribed “Just in Case” they are required to control symptoms using the latest prescribing guidelines. These medications should be reviewed by the prescribing clinician who should make decisions about continuing or discontinuing. (Medications should only be discontinued if they do not contribute to a person’s comfort or if they no longer are able to take medications orally).

Interventions should be regularly reviewed such as blood glucose monitoring, oxygen therapy, peg medications/feed, Clexane and decisions made about their appropriateness to give comfort.

Is there a valid DNACPR decision and lilac form, if so where will this be kept? If not then this should be discussed with the person and those important to them. Following discussions, if the person has a Cardiac Defibrillator device, follow local policy to have this de-activated in their best interest.

And

Do assess the following at least daily:

Nutrition and Hydration should be discussed with the person if appropriate and those important to them and decisions documented. Ensure the person is supported to take food and fluid by mouth for as long as possible and how are they currently receiving them. Is it adequate and appropriate taking into account the person’s swallow? Assess Hydration status daily.

Skin Care documentation should be continued such as water low/maelor score, interventions & equipment to maintain skin integrity, safety & comfort and pressure relieving regime.

Oral & Personal Hygiene is significantly important. Good mouth care is essential to avoid dry mouth and cracked lips. Information should be given and that these symptoms do not necessarily mean the person is dehydrated but more likely related to the person’s mouth breathing. What provision is available to maintain adequate oral and personal hygiene and how are needs met?

Continence can be managed by providing equipment. Following assessments has the person passed urine or had their bowels open? Do they require continence aids or catheter equipment?

Symptom management is essential and should be assessed if the symptom is there or not (pain, nausea/vomiting, agitation, chest secretions and dyspnoea). If symptoms are present, ensure you document actions to alleviate them.

Support the person and those important to them and give them the opportunity to discuss worries/concerns.

Environment is it appropriate, is there equipment available? Can privacy and dignity be maintained for the person and those important?

5 Principles of best practice in End of Life Care An Aide Memoire

Page 4

Patient Information NAME:

DOB:

NHS:

The person at end of life and those that are important to them should be treated at all times with care and compassion and should expect that the professionals supporting them will:

Communicate sensitively that end of life may be approaching.

Give the person (where they wish to) and those that are important to them the opportunity to be involved in developing the plan of care.

Continue to communicate with the person and those that are important to them in accordance with their wishes.

Name:

Diagnosis

Significant co-morbidities: (Other illnesses)

LASTING POWER OF ATTORNEY FOR HEALTH & WELFARE - YES NO Name:

ADVANCE DECISION TO REFUSE TREATMENT - YES NO

ADVANCE STATEMENT - YES NO

If YES Nurse assessing to view documents.

Those who are important to the person.

Name Relationship Contact Details: where appropriate.

First Contact Day Permission to contact

Yes No

Night Permission to contact

Yes No

Day Permission to contact

Yes No


Yes No

Day Permission to contact

Yes No


Yes No

PRINT NAME: SIGNATURE:

DESIGNATION:

DATE:

TIME:

Assessment

Page 5

Wishes and Preferences If the person does not wish (or is not able) to take part in discussions please take account of previously stated wishes and preferences.

NAME: ________________________________

DOB: _________________________________

NHS: _________________________________

Where would you like your care to take place?

What is most important to you at this time?

(wishes, thoughts, feelings & beliefs)

What would you like us to know about your preferences for your care?

What concerns or worries do you have?

(think about family, friends & pets)

What are your wishes for support to take food and fluid by mouth?

(Discuss risks and benefits of artificial

hydration)

Have you considered tissue/organ donation?

Information can be found www.organdonation.nhs.uk/ or 0300 123 2323

Other

PRINT NAME: SIGNATURE: DATE:

DESIGNATION: TIME:

Assessment

Page 6

Not applicable for Covid-19

http://www.organdonation.nhs.uk/

Nursing Assessment NAME: ____________________________________________

DOB: ______________________________________________

NHS: ______________________________________________

Is the person hydrated?Consider swallow.

(Please describe)

Is the person receiving food and fluid through another route e.g. Peg feed?

(Please describe)

Is the person’s mouth clean and moist?

(Please describe)

Does the person have issues

related to continence?

(Please describe products used)

Does the person have issues related to skin integrity?

(Please describe)

Continue with current care plans as per Policy

What equipment is in place?

What equipment is required?

Other


DESIGNATION: TIME:

Assessment

Page 7

Names of people involved in discussion: health professionals and those who are important to the person:

Medical AssessmentIt has been recognised that ………………………….. may die in the next hours or days by the person (where possible), those who are important to them (where possible) and the professionals caring for them.

Reversible causes of decline have been considered.

Name Relationship Record of Discussion

Does the person have capacity to make their own decisions? Yes □ No □ If no describe actions to support, consider best interest decisions and using an IMCA:

Symptoms Yes () No () Consciousness Level ()

Pain Conscious

Nausea/Vomiting Semi-conscious

Agitation Unconscious

Confusion Hydration Status (please describe):

Chest secretions

Breathlessness

Other:

Additional information:

(interventions to continue/discontinue)

Medication

Discontinue all oral medications Yes □ No □ Just in Case Medication prescribed Yes □ No □

If No please provide instructions below: If no please prescribe as per Guidelines

Doctor’s Name:

Signature:

Date:

Time:

Has a DNACPR decision been discussed? Yes □ No □ Please insert completed lilac form.

Does the person have an Implantable Cardiac device? Yes □ No □ If Yes what is the plan for care?

Assessment

Page 8

NAME: ________________________________

DOB: _________________________________

NHS: _________________________________

Care Plan The person and those important to them should be

offered the opportunity to be involved in the care plan

NAME: ___________________________________________

DOB: ____________________________________________

NHS: ____________________________________________

Preferred Place of Care:

Personal Care ……………………………………………..………. to continue with all aspects of personal hygiene

………………………………………………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………………………………………………

Spiritual and

Religious care

………………………………………………………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………………………………………...

Discuss and facilitate individual need

Support to take

food and fluid

…………………………………………………………………………………………………………………………………………………………

Encourage food if safe to do so

Encourage sips of fluid if safe to do so

……………………………………………….….. to discuss risks and benefit

……………………………………………….….. to assess/observe hydration status/skin turgor daily

Mouth care ……………………………………………….….. to provide regular oral hygiene

……………………………………………….….. Nurse to monitor at each intervention

…………………………………………………………………………………………………………………………………………………………

Bowels/bladder Care …………………………………………………… to monitor urine output

……………………………………………...…… to monitor bowel pattern

…………………………………………………………………………………………………………………………………………………………

Skin care

(if currently on a care

plan for skin care

please continue)

Monitor pressure areas at least daily

Liaise with care provider

………………………………………….………. provide regular repositioning

Complete risk assessments as appropriate (Waterlow/Maelor score)

…………………………………………………………………………………………………………………………………………………………

Symptom control

(consider pain N/V,

agitation, secretions

& Dyspnoea)

Nurse to monitor at each intervention and complete daily symptom assessment

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

Support for person

and those important

to them

Person where possible and those important to them to be kept fully informed

Encourage to ask questions or raise concerns

Inform GP

………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………...

Other ……………………………………………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………………………………………...


DESIGNATION: TIME:

Assessment

Page 9

Assessment

Page 10

Agreed Plan of Care This plan of care has been discussed with the person and

those important to them (where possible)

Record below with whom the discussion took place and

outcome.

N.B. This record will be appropriately shared with other Health &

Social Care Professionals involved in your care.

NAME: ______________________________________________

DOB: _______________________________________________

NHS: _______________________________________________

Summary of assessment including wishes and preferences

DISCUSSED WITH:

(Please document who is in-volved in discussions)

The Patient: I agree with the plan of care and give my consent.

Signed:

N/A please tick □

Date:

Time:

Those important to them: I agree with the plan of care.

Name

Signature

Relationship

Date:

Time:

Health Professional: Name

Signature

Designation

Date:

Time:

Date/Time Comments Name/Sign.

NAME: _________________________________

DOB: __________________________________

NHS: __________________________________


Nursing and medical


NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

Daily Care and CommunicationNursing and medical


NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



NAME: _________________________________

DOB: __________________________________

NHS: __________________________________


NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

Daily Symptom Assessment

Day 1 Date: __/__/__Please assess and document action/outcome at each nursing intervention, or 4 hourly the person’s experience of the following:

PAIN

NAME: TIME: SIGNATURE:






NAUSEA/VOMITING







AGITATION







ASSESS HYDRATION STATUS DAILY


NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



RESPIRATORY CHEST SECRETIONS







DYSPNOEA – (difficulty breathing)







OTHER







NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



PAIN







NAUSEA/VOMITING







AGITATION









NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

















OTHER







NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



PAIN







NAUSEA/VOMITING







AGITATION









NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

















OTHER







NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



PAIN







NAUSEA/VOMITING







AGITATION









NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

















OTHER







NAME: _________________________________

DOB: __________________________________

NHS: __________________________________



PAIN







NAUSEA/VOMITING







AGITATION









NAME: _________________________________

DOB: __________________________________

NHS: __________________________________

















OTHER





