Palliative Care
in Dumfries and Galloway
Staff Area
APC
APC is still applicable for patients at the end of life. Certain adaptations will need to be made to the general hospital APCs such as …
Some patients may be quite settled but require pre-emptative breakthrough prior to working with them – if this is the case, give the medication ~20 minutes to work, and note that it is a “pre-emptive dose” on the chart.
Observations
“Obs” are often inappropriate at EOL as they would not change patient management. This should be clarified with the team looking after the patient.
Mouth care
Regular mouth care is important for patients at end of life, as often they can struggle with a dry mouth, especially when on medications
such as buscopan.
Using saliva tablets or boitene gel, if the mouth is dry can help. In patients still able to swallow but troubled by dry mouth, pinapple
is sometimes helpful.
Health Education Englands Mouth Care Matters offers useful resources.
Blood sugars
At the end of life, the priority is to keep patients comfortable and tight glycaemic control is less important. However, it is still important to check for signs of high blood sugar (hyperglycaemia) or low blood sugar (hypoglycaemia ) as these can cause uncomfortable symptoms.
It is important to check if the patient has type 1 or type 2 diabetes, and whether they are on insulin. Long acting insulin should not be omitted – but the dose may need to be significantly reduced in patients who are not eating and drinking. Short acting insulin may be omitted if patients are not eating. Oral diabetic medications should be reviewed.
Steroids are sometimes used for symptomatic relief in palliative care, and can cause hyperglycemia. Blood sugars should be checked in patients on long term steroids, and insuling may be needed.
For more advice, see the Marie Curie knowledge network or speak to the local palliative care or diabetes teams.
Dalteparin
Treatment dose dalteparin should be continued until the end of life. It is not appropriate to continue prophylactic datleparin in patients who are actively dying. Contact the patients Medical team if you have any concerns about this.
Bloods and venflons
Bloods can be useful in palliative patients for monitoring renal function, anaemia and electrolyte disturbances. However when a patient is approaching end of life, this should be evaluated in discussion with the parent team and patient/family.
Subcutaneous fluids
0.9% NaCl can be given subcutaneously in hospital at a rate of no more than 50ml per hour. However, the administration of these should be discussed with the medical team, as they are often not appropriate.
Syringe drivers
Syringe drivers or CSCIs are used for patients who are unable to take oral medications due to:
• Persistent nausea or vomiting
• Dysphagia
• Bowel obstruction or malabsorption
• Reduced consciousness, such as in the last days of life
They can occasionally be used in patients who can manage oral medications and have difficult symptom control.
Volumes:
• 18ml in 20ml syringe
• 23.5ml in a 30ml syringe
• 34ml in a 50ml syringe
Water for injection is the diluent of choice, although some medications (including Dexamethasone) require 0.9% Saline – Ward B1 have a handbook.
It is acceptable to use 4 medications (plus Dexamethasone) in a syringe driver. Discuss with the SPCT if you have any queries.
When to start a CSCI:
For any of the situations outlined, it may be appropriate to start a CSCI. If a patient is approaching end of life, and has required two doses of breakthrough medications, a CSCI should be started for better symptom control.
Drug compatibility: if you are concerned about compatibility of drugs, contact Ward B1 who have a formulary book. If the solution becomes cloudy or precipitates, discuss with B1.
Subcutaneous cannula site problems – sites do not need to be changed unless the site becomes problematic. If a patient is having issues with multiple sites, 0.33ml dexamethasone can be added to the driver (add this last when making
the driver)
Symptom management
It can be difficult at the end of life when patients aren’t able to communicate to determine if they are uncomfortable. Pain assessment is described in other texts and guidelines, but general indications of pain in someone who is dying and unable to speak are grimacing, groaning and stiffness or resistance to movement. If you see any of these signs then you should give a breakthrough of whichever analgesic +/- anxiolytic is prescribed.
Symptom management
For respiratory secretions, positioning can be more effective than medicine, for example lying patients on their side, or up to 45 degrees. If a patient is on maximum dose Hyoscine hydrobromide (2.4mg locally) no extra breakthrough can be given for secretions. In this case, try positioning, suction and breakthrough if the patient is distressed.
Communication with the family is very important if a patient has noisy secretions, as it can often be distressing to listen to. Reassure those around that it is not unusual and consider suggestions such as music or the TV.
Giving breakthrough
When giving breakthrough, injection volumes should not exceed 2ml. The medication will need reviewed if this is the case. A 0.2ml flush should be given after breakthrough. If a patient is requiring multiple breakthroughs, consider using a separate subcutaneous cannula to the driver site.
Supporting Families
It is important that families feel supported at the end of life, as not all will be familiar with death and dying. When talking to families about what to expect, they should be told about: changes in appearance, common symptoms, such as secretions, and changes such as eating and drinking less, sleeping more. They should be encouraged to still talk to and hold hands with their loved one if they so wish. Useful resources for families can be found on the “useful resources for patients and families” page.
Escalation plans
Escalation plans are appropriate for all patients. When a patient has co-morbidities, frailty or palliative needs then this is even more important.
Escalation plans should give an indication about when ITU/HDU would be appropriate and if “Ward based Ceiling of care” then if further bloods, IV treatments and observations are appropriate.
There should also be a documented discussion about DNACPR for patients approaching end of life.
Escalation plans should always be discussed with the patient and/or family where possible.
A clearly documented escalation plan ensures that the whole team is aware of the situation. Handover is a good time to highlight any patients of concern and discuss with the team.
F.A.Q.s
Should I still give my patient steroids at the end of life?
Steroids can be useful for managing a variety of symptoms, such as stridor, pain and if the patient has been on steroids longterm, they should not be stopped. Dexamethosone can be given subcutaneously as a bolus in the morning.
What should I do with my patient’s fentanyl patch?
If a patient is on a fentanyl patch and approaching end of life, this should be continued and changed 72 hourly as per protocol. The dose of fentanyl will change the amount of analgesia given as breakthrough.
How often should I change the cannula?
Subcutaneous cannulas do not need to be changed unless the site becomes problematic – see the “Syringe driver” section for more information