Last days of life
In Wales, when people are identified as being in their last days of life, a care decisions tool may be used. This is based on the National Institute of Health and Care Excellence guidance: care of dying adults in the last days of life, 2015. Ideally, medical and nursing staff should carry out a joint assessment. The benefit of using this document is to record all decisions of the clinical team and agreed priorities of the patient.
There should be clear documentation of how the decision was reached that the person is likely to be in their last days of life. Some thought should be given to whether reversible causes of deterioration have been considered and whether further investigations are going to be suggested. There should be specific reference to decisions about hydration and nutrition and how these can be managed. A decision needs to be made on whether to monitor vital signs, whether blood tests should be done and if outpatient appointments are still important. If the person has an implantable cardiac device, management of this might be discussed with the cardiology department. Current regular medication should be rationalised after discussion with the patient. Patients and those close to them should be made aware of potential symptoms that are likely to occur in the last days of life, namely pain, breathlessness, nausea and vomiting, agitation, noisy respiratory secretions and delirium. Anticipatory medication can be prescribed with indications for their use, route of administration and dose, depending on patient characteristics:
§ Analgesic: Diamorphine/Morphine
§ Anti-emetic: Cyclizine
§ Anxiolytic: Midazolam
§ Anti-secretory: Hyoscine hydrobromide
If in doubt on what to prescribe and what dose to give, further advice should always be sought from a specialist palliative care consultant or nurse.
It is useful to ask a person if they have any wishes and preferences and clarify an advance care plan with them. Of absolute importance is the knowledge of whether there is a legally binding advance decision to refuse treatment and whether the person has appointed a lasting power of attorney for health and welfare. Cardiopulmonary resuscitation should be discussed with the person and their family. Forms will need to be signed if they decide to refuse resuscitation and a copy should be kept at their place of care and another should be retained at the GP surgery. People should be given the opportunity to disclose any cultural, spiritual and religious support that they would like to have.
The care decisions tool should be thought of as a dynamic document and process. People within their last days of life should be reviewed daily by a health care professional and informed of any changes regularly. This document reminds us of the importance of the multi-disciplinary team approach and capitalising on the number of people that can potentially support the patient.