Recognising and Managing Dying

Patients

Shoba Nair
Consultant in Palliative Medicine
Sheffield Teaching Hospitals
 Objectives

• To identify dying patients

• To manage dying patients

 Contents
• Background

• Guidance

• Management

• Care after death

 Key message
Care of the dying is everyone’s responsibility
 Background
• The 2015 report from the Parliamentary and
Health Service Ombudsman illuminated how
EOL care in hospitals can go badly wrong, with
patients and their relatives left unsupported

• Despite best intentions, delivering high-quality

end-of-life (EOL) care in the acute
environment is difficult
 Place of Death
• In 2016, 46.9% of
people died in hospital,
21.8% in care homes,
23.5% at home, 5.7% in
hospices (1)

• In 2004, 57.9% of
deaths occurred in
hospital
 Cause of Death
• In 2016 cancer
accounted for 28 % of
deaths in England,
circulatory disease
25.5%, and respiratory
disease 13.7%(1)
 Mrs. c
Mrs C , 64 yr. old lady admitted with bleeding
from her 2 stoma bags (1ileal, 1 colonic)-
Transfusions done. Previous hernias, intestinal
obstruction ( 10 years). Abdominal pain. Has had
several blood transfusions.

- Discussed with primary treating team

- Discussed with family members
- EOLC
 One chance to get it Right
• The Leadership Alliance for the Care of Dying
People (LACDP) produced the report One
chance to get it right: improving people’s
experience of care in the last few days and
hours of life in 2014 (2 )

• LACDP outlined 5 priorities for Care of the

dying
 Priority 1
• The possibility that a person may die within
the next few days or hours is recognised
• Communicated clearly
• Decisions made and actions taken in
accordance with the person’s needs and
wishes
• Regularly reviewed and decisions revised
accordingly
 Priority 2

Sensitive communication takes place between

staff and the dying person, and those identified
as important to them
 Priority 3

The dying person and those identified as

important to them, are involved in decisions and
treatments and care to the extent that the dying
person wants
 Priority 4

The needs of the family and others identified as

important to the dying person are actively
explored, respected and met as far as possible
 Priority 5
• An individual plan of care including
- Food and drink
- Symptom control
- Psychological, social and spiritual support

• All the above co-ordinated and delivered with

compassion
 Challenges
• Identifying the approach of the end of life

• Offering conversations on future treatment

choices
 Guidance
• SBAR (Situation-Background- Assessment-
Recommendation)

- Help structure a discussion

- Make an individualised plan of care for the last
days
- Provide ongoing review
Recognising the possibility of death in
the next few hours to days

• What has changed with the patient in the past

few weeks, days and hours?

• Is this reversible?
 Level of function changed ?
• Generalised weakness
• Change in oral intake
• Increasing falls/change in mobility
• Waking time shortened, spending more time
asleep
• Continence support required
• Persistent confusion
 Recognition of dying phase
• Is there evidence of progressive and
irreversible organ failure ?

• Have treatments or interventions been

ineffective, such as antibiotics, blood
transfusions, non-invasive ventilation, dialysis,
stents/drains, fluid/electrolyte replacement,
and medication changes?
 Recognition of dying phase
• Has the patient and/or those important to
them seen a change and decline or recognised
themselves that they may be dying?

With only limited or no reversibility, and a

progressive decline apparent, it suggests that
the patient may be dying
 Recognition of dying phase
• Assessment by a senior doctor who is
competent to judge whether the changes are
reversible
• MDT assessment should be clearly
documented in the notes
• Those important to the patient should be
identified and permission obtained to discuss
the situation with them
 SBAR- C (Conversation )

• Situation
- Identify to the person/ family the responsible
consultant and nurse in charge
- Describe how the person is
 SBAR- C (Conversation )
• Background
- What brought the patient to the hospital
- Sequence of events in the hospital
(investigations, findings)
- Treatment and interventions carried out
(antibiotics, interventions, fluids, steroids,
physiotherapy)
- Did the patient feel all the above helped, helped
initially and then stopped, caused other
problems?
 SBAR- C (Conversation )

• Assessment
- Convey that the patient is DYING (use this
specific word to avoid misunderstanding)
- Give a best time estimate (next few hours to
days)
 SBAR- C (Conversation )
• Recommendations
- Individualised plan of care for last days of life
incorporating the needs and wishes of the
patient
- Explain what procedures/interventions are no
longer necessary, and the rationale
- Where appropriate, discuss deactivation of
implantable cardiac devices
 SBAR- C (Conversation )
• Ensure DNACPR is discussed and form completed
• Explain that the following might happen
- Fatigue
- Sleeping more
- Spending more time in bed
- Eating and drinking less
- Difficulty taking oral medication
- Needing help with elimination if too tired to get to the
toilet
- Changes in circulation and breathing, including noisy
breathing
 SBAR- C (Conversation )
- If appropriate, convey the uncertainty in the
expectation of death being the likely outcome

- Explain that there may be a chance that the

patient recovers, in which case the situation
will be reviewed, with consideration of
restarting some of the discontinued
interventions and/ or medication
 SBAR- C (Conversation )
• Identify if the patient, or those important to
them have any specific emotional or spiritual
needs

• Discuss if referral to the hospital chaplain or a

faith leader from their own community would
be helpful
 SBAR- C (Conversation )
• Identify if there are specific cultural needs
relating to dying or death
• Discuss if the patient has any specific
preference for the place of their death; to
then consider if this can be realistically
achieved.
• Discuss if the patient wishes to consider tissue
donation, if appropriate
 SBAR- C (Conversation )
• Identify if there is any other information that
would help
• Ask if there are any remaining questions
• If a patient or those important to them disagrees
with the clinical team’s opinion, despite careful
explanation for its basis, a second opinion should
be offered
• Document the conversation and agreed plan of
care within an individualised plan of care for last
days of life
 Management
• Ensure comfort and allow natural death
- Rationalise oral and other important medications
- Consider alternate routes like subcutaneous route and
or syringe driver ( SD)
- Pre-emptive prescribing for anticipated symptoms
- Fluids/nutrition as appropriate
- Assistance with elimination
- Mouth care and pressure area care
- Blood tests and observations , only when indicated
 SBAR – D ( Daily Medical Review )
• Daily reviews
- Symptom management
- Nutrition/hydration
- Whether PRNs are effective
- Consider syringe driver if PRN more than two
times required for the same symptom
- Are there any signs of recovery ?
- Communicate and document
 SBAR - R ( Recovery )
• Communicate this to the patient and or the
important members
• The patient could be
- More awake and alert
- Swallowing, eating and/or drinking more
- Interacting more
- Sitting up/sitting out
 SBAR - R ( Recovery )
• Treatment options to be clarified
• Re-introduce blood tests/ observations if
appropriate
• Re-introduce certain medications if appropriate
• Re- introduce hydration/nutrition if appropriate
• Review nursing plan - 4 hourly checks
• Be mindful that the improvement may be
transient and conversation will be required if
deterioration reoccurs in the future
 Care after Death
• Verification done within one hour
• Notification given by the member of the
nursing /medical staff
• Cause of death decided after consideration by
the Medical Examiner
• An appointment is made with the
bereavement office for the family/relatives to
return to the hospital and collect the medical
certificate of the cause of death (MCCD)
 Key points
• Care of the dying is everyone’s responsibility
• The possibility is a team consideration
• This is communicated appropriately after
excluding all reversible causes
• Use SBAR format – Situation – background –
assessment- Recommendation
• Lack of capacity – adhere to Mental capacity
Act 2005/LPA/IMCA
 References
1. https://www.gov.uk › End of Life Care Profiles:
February 2018 update

2. Leadership Alliance for Care of the Dying

Person, (2014) One chance to get it right,
available via:
https://www.gov.uk/government/uploads/syst
em/uploads/attachment_data/file/
323188/One_chance_to_get_it_right.pd
Death