Acute hospitals are perfect for emergencies, surgeries, fixing, curing and treating patients, making them well again and sending them home. When it comes to dying in an acute hospital, sometimes we need some help and guidance to know how to care for these vulnerable patients and what is needed at this point of life. Providing care and dignity are basic human values and should be given to patients regardless of the situation.
Recognising a patient is in their last days of life can be difficult and often uneasy, especially when discussing with the patient and their loved ones. In 2017, there were 1109 deaths within my local health network. A quarter (277) of these patients died in the hospice setting, leaving 75% (832) dying in an acute setting, with a non-specialist palliative care team looking after them. Whilst it’s possible to count the number of deaths, it’s not possible to ascertain from those numbers the quality of the care they received leading up to death. People facing the last days of their life have specific care needs, here are three tips to improving the quality of care patients and their loved ones receive.
- Recognise when the patient is dying
Sometimes recognising a patient is dying can be quite unpredictable, but often we can anticipate the deterioration. Some of the clinical signs can be subtle and fluctuating and our impressions are often based more on ‘gut feelings’ than clear evidence. In a cancer setting there are several studies describing how health care professionals recognise deterioration and impending death. Figure A shows the clinical signs and symptoms that occur in the last few days of life and allow for a more objective evaluation.
Figure A
- Communicate with and support the patient and his/her family
Families often report they don’t know what is happening, needing to piece all the snippets of information together. It is important we provide information and communicate clearly with families and caregivers, especially in the last days of life. Offering a time to meet with families to answer questions and provide an update on the patient’s condition is often undervalued by healthcare professionals. Providing printed information to loved ones of what to expect at end of life, with supportive conversation has proven to be helpful in understanding the situation. This allows the family and caregivers to read, in their own time, some of the symptoms their loved one may experience. It often answers questions families have and provide an overview of what to anticipate in the last days of life.
This is also a time to involve the allied health team such as social work and the spiritual care team to provide another layer of support to the patient and their family. If there are specific cultural traditions, it’s crucial to ask how we are able to assist with facilitating these needs.
- Document the discussions
It is imperative that conversations regarding patient deterioration and end of life are documented clearly. If the patient has an Advance Care Directive (ACD) it would be important to ensure we are aware of their wishes regarding end of life care and who they have nominated as their Substitute Decision Maker (SDM).
In a busy acute care setting, there are multiple medical teams, nursing and allied health staff that may have involvement in patient care. It’s important to accurately document the discussions that have been had with a clear direction and plan of care for each patient. This allows any member of the multidisciplinary team to clearly understand the current situation.
The dying patient still has medical, nursing, psychosocial and allied health needs.
End of life care is everyone’s business.
Resources
Webpages and apps:
CareSearch – Information for – GPs – The Dying Patient - Assessing the Dying Patient
CareSearch – Information for – GPs – The Dying Patient - End of Life Symptoms
palliAGED – Practice Centre - palliAGEDgp app
palliAGED – Practice Centre - palliAGEDnurse app
YouTube video links:
End-of-Life essentials – Dr Tracey Giles – A Clinical Story
End-of-Life essentials – Professor Imogen Mitchell – Dying in the 21st Century: An ICU perspective
End-of-Life essentials – Professor Imogen Mitchell – Communication: An ICU perspective
Dignity in death – are hospitals failing those needing end of life care?
Journal articles:
Murray S, Kendall M, Boy, K, Sheikh A, 2005, Illness trajectories and palliative care, The BMJ, vol.330, 1007-11
Cox K, Moghadda, N, Almack K, Pollock K, Seymour J, 2011, Is it recorded in the notes? Documentation of end-of-life care and preferred place to die discussions in the final weeks of life, BMC Palliative Care, vol.10, no.18
Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA, et al., 2008, Evidence for improving palliative care at the end of life: a systematic review, Ann Intern Med, vol.148, no.2, 147-59
Hui D, Santos R, Chisholm G, Bansal S, et al., 2014, Clinical signs of impending death in cancer patients, Oncologist, vol. 19, no.6, 681-687
Advance Care Directive (SA):
https://advancecaredirectives.sa.gov.au/
Maite Uribe, Nurse Practitioner Candidate, Southern Adelaide Palliative Care Service