Urinary catheter use in end of life care

Authors

Jane Young is continence nurse specialist; Colette Conway is district nurse team leader and end of life chair; both at Hillingdon Community Health, Central and North West London Foundation Trust

All patients should have access to high-quality care as they approach the end of life (Department of Health, 2011; 2009). In recent years, end of life care has been led by community and specialist palliative care nursing teams.

The General Medical Council’s new guidelines for general practitioners on end of life care include guidance on collaborative decision-making with community nursing teams (GMC, 2010).

The End of Life Care Strategy (DH, 2008) highlights the importance of an agreed plan of care and regular reviews of patients’ needs, and the Gold Standard Framework (www.goldstandardsframework.nhs.uk) says pre-planning ensures more consistent care.

End of life bladder management

Watson et al (2006) define the terminal phase of life as the period when day-to-day deterioration occurs, especially in appetite, awareness and strength. It is during this phase that a full bladder (or bowel) can cause patients to become increasingly agitated or restless (Box 1).

By anticipating patients’ needs, health professionals can initiate an immediate response when necessary. Patients’ treatment or care plans should clearly indicate what intervention is required if their condition deteriorates (Watson et al, 2006). If this phase is not managed well, relatives can be left with a memory of their loved one dying in distress. But if proactive measures are in place, the dying patient will have care and support, meaning relatives and carers are left with positive memories of the dying process (Watson et al, 2006).

Continence care at the end of life should be based on the patient’s wishes and preferences (Harris, 2009). While bladder management may be discussed in the palliative stage, it is often dealt with in a reactive way by providing containment products and skin care at the terminal stage.

Choosing the right management option requires a good understanding of bladder dysfunction, and the clinical skills to assess the patient’s current and potential needs.

Urinary catheterisation

Many senior community nurses have extended roles, such as independent prescribing and advanced physical assessment, and can identify when urinary catheterisation is needed.

Where this is considered the most appropriate management strategy, nurses must obtain consent from the patient’s GP. This poses a dilemma if medical consent cannot be obtained, for example out of surgery hours. Nurses can feel vulnerable, and the fear of causing harm to patients at the end of life can mean they refuse to perform the procedure. In some circumstances, patients may be sent to A&E to be catheterised. This goes against the aim of caring for patients at home, especially if home is their stated preferred place of care.

Catheterisation consent form

Hillingdon Community Health’s local end of life care strategy states district nurses should be the key workers responsible for coordinating end of life care.

There are 10 district nursing teams in the borough and the service operates seven days a week. A representative from each team attends a monthly meeting, along with other health professionals involved in end of life care, such as the specialist palliative care team and community matrons. The group ensures care is standardised across the borough, discusses issues or initiatives, and implements changes.

It is routine practice to pre-empt the need for specialist equipment and anticipatory medication in end of life care and we felt the same approach should be taken with bladder management. This would empower nursing staff to provide the best possible care to patients and their families.

The group was unable to find any reference to end of life catheterisation in trust policies, so a urinary catheterisation consent form was devised. This included the rationale for end of life catheterisation, patient identification details, and a statement for the GP to sign giving permission to catheterise the patient if required and the trust policy on indwelling catheters in end of life care (Box 2).

The form was signed off by the trust’s medical director and clinical governance team and incorporated into the trust’s urinary catheter policy and district nursing end of life standards. It was then distributed among the group and all district nursing teams.

It is now standard practice to discuss the consent form with the patient and GP when discussing anticipatory medicines and specialist equipment. Once the GP has completed the form, it is kept in the patient’s home notes; if the need for catheterisation arises, there is no delay in performing the procedure, preventing unnecessary discomfort to the patient.

Discussion

The urinary catheterisation consent form is designed to support community nursing staff in planning and implementing strategies in end of life bladder management.

The aim is to avoid terminally ill patients being sent to A&E to be catheterised, something that has not happened at the trust since the tool was implemented in October 2010. The tool has also helped promote discussion between patients, nurses and GPs.

The consent form received positive feedback from community nursing staff and GPs, especially the twilight nursing team who see patients up to midnight.

Although it was developed for use in end of life care, the form could be adapted for use with other patients with progressive bladder dysfunction, such as those with multiple sclerosis.

Conclusion

The fact that only medical professionals can authorise urinary catheterisation has never been challenged by nurses, yet it is nurses who become highly skilled in catheter assessment, insertion and management.

National guidance for nurses on end of life catheterisation would ensure standardised practice, and health professionals should continue to look at ways to proactively manage patients approaching the end of life.

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