Palliative and End of Life Care

The information provided below is also available to download as an end of life factsheet and Q&A.

Update 12 May 2020 – New EPIC ORDER for patients dying from COVID

For patients dying from COVID there is a new collated drug Order for symptom management available on Epic.

This includes the longer acting drugs haloperidol and levomepromazine for management of terminal agitation.

This can be ordered on Epic by typing ‘Last days’ into the Order box and selecting the COVID option (it is NOT an order Set).

Please be aware that the lowest doses in the given dose range should be used first as prn SC doses, then assess the patient’s response and use the higher doses only if needed.

For further advice the palliative care team can be contacted as below:

  • Palliative Care Specialist Nurse available 09:00 – 17:00 every day  on 07592 593221.
  • Palliative care Consultant available 09:00 – 17:00 every day  on 07703 469912 AND via switchboard out of hours.
  • Palliative Care Office ext. 274404 answer phone.

1. Is the palliative care team available for COVID and non COVID patients?

Yes, palliative care can help with the following:-

    • Symptoms not responding to clinical guidelines including when a patient is imminently dying.
    • Complex symptoms for patients already known to Palliative Care Team
    • Decisions not to escalate treatment in the phase of deterioration or uncertain prognosis
    • Other complexities e.g. communications with relatives and discussing uncertain outcomes.

2. How do I refer to Palliative Care Team?

Refer by ordering on EPIC or ringing 274404.

Specialist Nurse advice is available 09.00 – 17.00 every day on 07592 593221

Consultant advice available 09.00 – 17.00 every day on 07703 469912 and via switchboard out of hours

3. When is the Bereavement Care (BC) office open?

The BC office is open 08:00-16:00 Monday to Friday and there is a reduced service at the weekends and bank holidays, between 10:00-14:00. You can ring on x217537/217539. Please continue to ask relatives to ring the office the day after the death.

4. Are you able to collect the medical cause of death certificates from the wards?

The bereavement care team will collect certificates from the wards. Please ring the office to let them know it is ready for collection.

5. What do we do with deceased patient’s property?

When a patient dies, their property should be bagged, labelled and accompanied with a property form. Due to the restriction in visiting, a service is now available to support the ward areas to return property to relatives.

Please bag the property and place a label on the outside.

Wipe down any surfaces if able.

  • Complete and print a property form.
  • Call 254827 and leave a message advising you have patient property for collection stating the clinical area, patient name, MRN and date of death.
  • The team will collect and transfer to a green storage facility, schedule an appointment and return the property to the next of kin in person.
  • Advise the next of kin that they will be telephoned and an appointment will be made to meet someone face to face to return their loved ones belongings.

6. How do families register deaths since the registration service has been suspended?

Registering deaths is now done on the telephone so BC would ask you to tell the relatives to ring the office after 10 am the following day and BC will give them all the information that they need. Alternatively they can go online www.cambridgeshire.gov.uk

7. Is chaplaincy available for COVID and non COVID Patients?

Yes, chaplaincy can help with the following:

  • Liaising with the family
  • Being present for video-calls
  • Offering religious or ritual input
  • Supporting staff during and assisting in breaking the bad news.
  • Accompany relatives visiting the ward providing emotional guidance/support

8. Will chaplains still come to the wards?

Yes

9. Is chaplaincy available for staff whom require support?

Yes, involving chaplaincy in the care of dying patients can alleviate some of the emotional demands upon staff, and it is fine to involve chaplaincy for the benefit of staff regardless of patient/family need. Reducing the emotional load and discomfort experienced, can aid resilience and wellbeing. This may be particularly helpful if the staff involved have less experience in these aspects of care or would benefit from lightening their load.

10. How do I communicate with patients and their families?

There is a tip sheet – talking to relatives which should be available on all of the wards

11. What information is needed in discharge summaries?

To avoid readmissions the key information required on discharge summaries is;

  • Anticipated Prognosis (days/weeks/months)
  • Expected future care plan (e.g. patient wishes to avoid readmission and to die in hospice, OR patient does not want intensive interventions but DOES want readmission for iv antibiotics if indicated)
  • Anticipated care in the event of deterioration

(e.g. if a known risk of problems such as seizures, the discharge summary should include a clear plan for community management of this anticipated problem,  OR if deteriorating  from potentially reversible changes in a chronic condition or new acute problems  give guidance about  active treatment +/- readmission.)

12. Where can I access advice on medicines?

  • Pharmacy services continue as per services pre-COVID 19.
  • Often provided remotely in Scenario 1 and 2 areas to reduce footfall in these areas
  • Each division will have a contact number to escalate issues or to seek advice
  • Medicines Information can be contacted on extensions: 596498/586862/348745
  • Please leave a message and the staff will call you back promptly

13. How do I obtain more stock of injectable medicines when working on COVID wards?

  • Check stock levels and order during normal working hours
    • Contact Central Pharmacy , Monday to Friday 09:00-17:00 extension 217500 for non-Controlled Drug orders
  • Controlled drug order modified on 22nd April for:
    • Critical care areas,
    • Emergency Department
    • Scenario 1 and 2 wards
  • All controlled drugs required for the above wards must be ordered via the ward pharmacist (or on-call pharmacist if out of hours; or pharmacist in Inpatient Pharmacy at weekends).
    • The on-call pharmacist can be contacted as follows: Mon – Fri 18:00 – 00:00 / Weekend/BH 16:00 – 00:00 – Bleep 152 881; 00:00- 09:00 (10:00 – Sundays & BH) – via Switchboard.
    • Nursing staff must complete daily checks of CD stock overnight to advise the pharmacist each morning which controlled drugs need to be ordered
    • The pharmacist will complete the CD order in the CD order book and arrange dispensing
    • CDs in most cases will be delivered to the ward entrance by the pharmacist
    • The nurse collecting must be ‘clean’
    • The nurse will be asked to sign the order sheet to acknowledge receipt
  • Ad-hoc ordering of controlled drugs during the take can take place- nursing staff should contact their pharmacist

14. What supply of injectable medicines should be made on discharge?

Discharging patients with injectable medicines for EOLC in the community:

Scenario Supply Flushes NaCl 20ml x 20 Diluents WFI 20ml x 20
Patient already established on syringe pump

Prescribe on TTO via ‘outpatient syringe pump’ order

Ensure prescribed as mg NOT ml

Separate orders of each drug will be required for supply purposes.

Consider the legal requirements for directions

 

7 days plus additional supply for PRN doses Yes Yes
Patient already established on PRNs SC

 

7 days supply – estimate on last 24 – 48 hrs use Yes – they may be administer via SC port (SAF-T Intima) No
Patient likely to deteriorate within the next 2 weeks

 

Supply 5 ampoules of each of the medicines

 

Yes – they may be administer via SC port

(SAF-T Intima)

No

15. What might I expect to see if someone is dying of COVID-19?

The same symptoms we already know may be associated with dying: pain, nausea, breathlessness, agitation and respiratory secretions. The most common symptoms of coronavirus that require attention are: breathlessness, cough, fever and delirium.

Therefore assess the symptoms the patient has and give PRN medication. The delirium can be the most challenging and may be terminal restlessness and require higher doses of medication than the wards usually give. Call palliative care team for advice.

We have local guidelines for care of dying adults.

Despite the challenging circumstances of the coronavirus pandemic, it is important not to lose sight of the important elements of holistic care of the dying person. This includes:

  • Effective communication including clear decision-making
  • Adequate pain and symptom management
  • Opportunity to prepare for death, including emotional and spiritual support (chaplains and faith leaders play an important role here)
  • Support for those close to the dying person, including the ability to keep in touch via phone or virtual communication (for example, Skype, WhatsApp)

https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0081-AMENDED-Speciality-guide-Palliative-care-and-coronavirus-v2-2020-04-22.pdf