Care of the Dying Patient - Nursing Assignment Help

Assignment Task

TARGET AUDIENCE 

This guideline is intended for clinical staff, particularly medical and nursing staff, involved in the care of dying patients on the wards and in the critical care areas of the hospital such as the ICU and ETC. 

PURPOSE 

The purpose of this document is to provide guidance for clinical staff in providing care to patients who are in their final hours or days, when death is expected. This guideline is designed to improve the care provided to dying patients on the wards by prompting consideration of important aspects of their management. This includes symptom control, reduction of unwarranted interventions and communication with the patient and their family. 

GUIDELINE 

The ultimate goal is to maintain the patient's dignity and comfort at all times. It is important to regularly observe and monitor patients to achieve good symptom control. The Care of the Dying Patient Plan - Symptom Observation Chart (SOC) is used to record these symptoms (Appendix 2). The SOC should be commenced once the medical team have identified that this patient is imminently dying and the Care of the Dying Patient Plan (CDPP) - Medical form has been completed (Appendix 1). Nursing staff should confirm with the medical team that there is no longer a need to record vital signs and that appropriate Goals of Care have been documented for the patient. Any available advance care planning documents should be accessed and reviewed when caring for the dying patient. Symptom Observation Chart (SOC) Appendix 2 A full set of observations must be recorded at least 4 hourly. Each set of observations must be correctly timed, dated and documented in black/blue ink. 

Symptom observations should include (but not be limited to); 

Pain Restlessness and agitation Breathlessness (dyspnoea) Secretions (gurgly breathing) Nausea and vomiting Involuntary jerking (myoclonus)  

Symptoms should be rated according to absent, mild, moderate or severe. The rating is based on the patient's reporting and/or the nurse's clinical assessment of the patient. 

Additional observations/comments should include: 

Voided 

Bowels open 

• Repositioning 

Mouth care 

• PRN medications provided 

The escalation guidelines should be used to determine the action to take if symptoms are present. Evidence of this escalation should be documented in the escalation row on the SOC and the action taken documented in the clinician comments section. The SOC should be discussed /shared with the patient and/or those closest to the patient as appropriate. Relevant family/carer information can be recorded in the appropriate box on the SOC. 

Document nursing care in patient's notes once per shift, ensuring all goals of comfort care are met. 

PRACTICE GUIDELINE TITLE: Care of the Dying Patient 

The following table provides guidance for providing care for the dying patient. 

Hoe GOAL The patient is not distressed by pain. 

WHAT TO LOOK FOR Verbalised by patient if conscious If unconscious observe for non-verbal cues e.g., grimacing, groaning or a high respiratory rate? Comfortable on movement Exclude reversible causes e.g. urinary retention and constipation Consider need for positional change Consider prn analgesia prior to nursing interventions e.g. repositioning Pain Assessment Tool maintained 

The patient is not agitated or distressed by restlessness. 

The patient has no nausea or vomiting. Oral secretions are not causing distress. 

Breathlessness is not a problem. 

Patient does not display signs of delirium, restlessness, thrashing, plucking, twitching Exclude reversible causes e.g. urinary retention, constipation and noisy environment Verbalised by patient if conscious Consider positional change Note if the presence of secretions is associated with distress. Often, patients are not distressed by this and families should be reassured Discuss symptoms & plan of care with patient, family/other Nurse with head above 30°, position patient on side If possible, avoid deep suctioning as likely to cause distress Patient verbalises if conscious Consider need for positional change Use of a fan may be helpful If respiratory rate above 30 bpm see the dyspnoea algorithm even if unconscious Continue oxygen if providing symptomatic relief Use of pads, urinary catheter if in retention Mouth care assessment at least 4 hourly Relative or carer involved in care, as appropriate Frequency of mouth care depends on individual need Frequency of repositioning should be determined by patient's individual needs Regular assessment as per Braden/Waterlow Skin, eye care according to individual needs Relative or carer involved in care giving as appropriate Refer to Advance Care Directive if applicable for patient preferences Spiritual, religions/ cultural needs – consider support of the pastoral care team Refer to Advance Care Directive if applicable for patient preferences 

The patient has no urinary or bowel problems. Mouth care is provided for comfort. 

Skin integrity and pressure area care is maintained. 

Personal hygiene needs are met 

Care is given in a personalised physical environment, which is comfortable for both the patient and their family. Support is provided for the patients' psychological well being 

Caring for the family/ loved ones of the patient 

The hospital environment can be overwhelming for the family/loved ones or carer of the patient. It is important to ensure that their well-being is maintained, and necessary support provided. This may include: 

Providing a supportive environment for family/loved ones to spend time with the patient Offering to provide a social work referral Offering to provide pastoral care / meet religious or spiritual needs Consider a referral to the Grief Counsellor (via Palliative Care) Offering end of life rituals which may be important for the patient and their loved ones Ensuring family/loved ones are aware of facilities available e.g. tea/coffee, toilets 

APPENDICIES 

1. Care of the Dying Patient Plan (CDPP) - Part A (Medical) 

2. Symptom Observation Chart - CDDP Part B KEY RELATED DOCUEMENTS 

• Key legislation, acts and standards: 

O Charter of Human Rights and Responsibilities ACT 2006 o Australian Commission on Safety and Quality in Healthcare (2015). National Consensus 

Statement: Essential elements for safe high-quality end of life care. Sydney, ACSQHC. www.safetyandqulaity.gov.au 

Modified from Alfred Hospital Care of the Dying Patient Guideline November 2018 

PRACTICE GUIDELINE TITLE: Care of the Dying Patient SYMPTOM OBSERVATION CHART - PART B 

DOCUMENTATION Advance Care Plan in patient EMR (review end of life wishes if available 

Yes 0 No Consensus Resuscitation Plan completed (must be completed before proceeding) 

Dyspnoea (Breathlessness) 

Moderate 

Mild 

Absent Respiratory Tract Severe Secretions (Gurgly Moderate breathing) 

Mild 

Absent Nauseal Vomiting Severe 

Moderate 

Mild 

Absent Involuntary jerking Severe (myoclonus) Moderate 

Mild 

GENERAL INSTRUCTIONS A full set of symptom observations must be recorded at least 4 hourly The Symptom Observation Chart should be used in conjunction with Care of the Dying Patient Plan - Part A (Medical) The Symptom Observation Chart should be discussed/ shared with the patient and/ or those closest to the patient as appropriate Follow the escalation guidelines to determine the action to take and document 

Severe 

ESCALATION GUIDELINES Nurse in charge or delegate to escalate to medical unit Intervention & escalate to medical unit Intervention Continue Observations 

COMMUNICATION EXPLANATION OF DYING PATIENTS CARE 

Indicate below if relevant individuals have been informed that the patient is dying and if a family meeting has been offered and/ or such a meeting has occurred. If a given individual has not been informed or no family meeting has been offered/ occurred, then take measures to inform appropriate individuals and involve them in appropriate discussions. 

Rationalel Comments if “No" 

Patient informed Family/ carer informed LMO informed Family meeting held Coroner's case: Yes I If yes, family informed 

GOALS OR CARE REVIEWED 

Resuscitation guidelines should be revised in the last days of life. MET calls for symptom distress are still appropriate. It is important to ascertain if an Advance Care Plan is available and follow as appropriate. 

Medical EPOA: Yes I No I REVIEW OF CURRENT INTERVENTIONS/ THERAPIES 

Current interventions should be assessed, and non-essentials discontinued. Note: the patient should be supported with oral intake as long as tolerated. 

Regular medications Recording of vital signs Oxygen therapy Intravenous antibiotics Routine bloods including BSL monitoring 

Implantable Cardio converter Defibrillator (ICD) O YES O NO 

Modified from Alfred Hospital Care of the Dying Patient Guideline November 2018 

PART A 

MRN: Family Name: Given Name: Date of Birth: Gender: M O 

Medications must be prescribed and available in anticipation of symptoms which may develop. Anticipatory prescribing is recommended in end of life care. 

Agitation/ restlessness | Confusion/ delirium 

Respiratory tract secretions Nausea and vomiting Dry mouth PSYCHO-SPIRITUALI SOCIAL CARE NEEDS 

It is important that the dying patient and their family are given the opportunity to discuss what is important to them (i.e. wishes, feelings, faith, beliefs, and values etc 

L Social work Grief counsellor INDIVIDUALISED CARE NEEDSI OTHER MATTERS 

Modified from Alfred Hospital Care of the Dying Patient Guideline November 2018 

PART A 

MRN: Family Name: Given Name: Date of Birth: Gender: M O 

The possibility that a person may die withing the next few days or hours needs to be recognized and communicated clearly, having ensured that reversible causes have been excluded. All decisions made and actions taken should be in accordance with the person's needs and wishes and should be regularly reviewed. Wherever possible this should be done within working hours, by a senior clinician, ideally the | responsible consultant. 

COMMUNICATION 

In conjunction with commencing the CDPP a DISCUSSION should occur with the patient and their family and be documented in the medical notes. Interpreters should be used as appropriate. 

The discussion should include but not be limited to the following issues: 

• Prognosis: why death is likely and estimated prognosis (hours, hours-days, days etc.). 

• Nature of the dying process: explanation of what can be expected as someone becomes less 

conscious. 

• Symptom management: explain measures to manage symptoms associated with dying (i.e. pain, 

dyspnea, agitation etc.) and where appropriate the use of a continuous subcutaneous infusion. Daily 

medical review with a minimum of 4 hourly symptom assessment by nurses as stated. 

• Discontinuation or continuation of current therapy: what interventions, therapies and 

medications will be discontinued or continued and why 

• Advance care planning: establish if prior documentation exists regarding patient's end of life wishes 

(i.e. medical enduring power of attorney, advance care plan/ directive etc) and follow as appropriate Family involvement: establish extend to which family are to be involved in care and ensure contact 

details documented 

• Psycho-social wellbeing: establish cultural, spiritual and psychosocial needs of patient and family,  and facilitate end of life wishes where possible. 

INDIVIDUALISED PLAN 

A care plan tailored to the individual needs of the dying person and those identified as important to them should be developed and continually reviewed. This CDPP does not preclude the use of clinically assisted nutrition or hydration or the use of other therapies as clinically indicated for an individual patient. 

REVIEW 

This CDPP should be a continuum. The dying person's condition, needs and wishes should be reviewed at least daily by the treating team. A full reassessment should be triggered when there is a significant improvement in the overall clinical condition. The CDPP can be discontinued in the event that the person's condition improves, and new goals of care must be developed and initiated.

 

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