Palliative Care
in Dumfries and Galloway
Staff Area
“Diagnosing dying”
It can be difficult to recognise the terminal phase of a patient’s life, and some patients will deteriorate more rapidly then expected. There are some signs that are common in the last days/hours of life:
• Requiring more assistance
• Getting out of bed less
• Reduced intake
• Reduced urine output/new
incontinence
• Extreme fatigue/sleepiness
• Changes to breathing patterns
• Change to facial appearance
• Skin mottling
If in doubt, contact the Specialist Palliative Care Team for further assessment
Principles
The Scottish government has set out four key principles for care in the last days of life:
1. Informative, timely and sensitive
communication is an essential component of each individual person’s care
2. Significant decisions about a person’s care, including diagnosing dying, are made on the basis of multi-disciplinary discussion
3. Each individual person’s physical,psychological, social and spiritual needs are recognised and addressed as far as possible
4. Consideration is given to the wellbeing of relatives or carers attending the person
Medication
For specific palliative medications advice, see the “anticipatory prescribing” page
Medicines: review and stop any treatments not consistent with the agreed goals of care.
Choose an appropriate route: if patient is able to swallow continue with oral medication that is
appropriate; stop unnecessary medications. If they are having difficulty swallowing consider changing to liquid formulations or change to the subcutaneous (SC) route if preferred (or unable to swallow). Consider the need for a SC infusion of medication via a syringe pump.
Make sure anticipatory medications for common symptoms are available and prescribed for as required use, by the oral and SC routes.
Management
Regular, planned review and documentation of the care plan will make sure the best care is given as the patient’s condition deteriorates, stabilises or improves.
Food and drinks: support the patient to take these as long as they are able and want to.
Comfort care: usually includes an alternating pressure (air) mattress to minimise avoidable skin breakdown due to overall deterioration of condition; repositioning for comfort; eye care; mouth care; bladder and bowel care.
Assisted hydration or nutrition: consider the benefits and risks; review plan regularly.
It is unclear whether assisted hydration contributes to respiratory secretions. Where indicated, a slow SC fluid infusion may be considered on an individual basis (see Subcutaneous fluids guideline in Scottish Palliative Care Guidelines).
Consider emotional, spiritual, religious, cultural, legal and family needs, including those of children and people with cognitive impairment or learning disability.
Bereavement: identify those at increased risk; seek additional support.
Communication
Discuss the care plan with the patient, if possible, and the family, and explain what changes to expect in the patient’s condition.
Sensitively explore wishes regarding organ and tissue donation where appropriate.
Make sure family members are aware of the care plan. Record a plan of how and when to contact the family if the patient deteriorates or dies.
Hand over care plan to other team members: hospital at night team, general practitioner, community nurses; out-of-hours community services. See the Scottish Palliative Care Guidelines about OOH handover.