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Innovation

Urinary catheter use in end of life care

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A urinary catheterisation consent form for end of life care in the community prevents delays in care, improves patient comfort and supports preferred place of care wishes.

 

In this article…  

  • Bladder management in end of life care
  • Anticipating patients’ needs in bladder management
  • A system that ensures terminally ill patients are catheterised at home instead of being sent to A&E for the procedure

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

Abstract

Young J, Conway C (2011) Urinary catheter use in end of life care. Nursing Times; 107: 29, early on-line publication.

Patients nearing the end of life can become agitated by a full bladder and may need urgent urinary catheterisation.

However, urethral catheterisation needs authorisation by a doctor. Nurses at a London trust developed a urinary catheterisation consent form permitting nurses to perform this procedure when it becomes necessary without having to gain medical authorisation.

This article discusses how the consent form can help improve bladder management, ensuring terminally ill patients do not have to attend the emergency department to be catheterised.

Keywords: End of life care,Urinary catheterisation,Consent,Community

  • This article has been double-blind peer reviewed

5 key points

  • A full bladder or bowel in the terminal phase of life can cause patients to become agitated and restless
  • Choosing the right option requires an understanding of bladder dysfunction and skills to assess patients’ needs
  • Urethral catheterisation for the first time requires verbal or written agreement from the patient’s GP
  • A urinary catheterisation consent form should include the reason for it, patient identification details, and a statement for the GP to sign giving permission to catheterise
  • National guidance for nurses on end of life catheterisation are needed to standardise practice

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).

Box 1 . Indications for catheterisation at the end of life

  • Management or prevention of wound damage, such as sacral pressure ulcers, and soreness of the anus, perineum, vulva and penis
  • Painful movements needed because of frequent changes of bedlinen needed due to incontinence
  • Pain or difficulty getting in and out of bed to use a commode
  • Urinary incontinence associated with obstruction
  • Urinary retention and/or distended bladder: common causes of retention in the terminal phase are constipation and morphine

Source: Kyle (2010)

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.

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).

Urinary catheterisation policy 2010 – the use of indwelling catheters in end of life care

End of life continence care is an essential part of ensuring comfort and dignity. Management of urinary problems at the end of life often involves the containment of incontinence and the management of urinary retention

Indications for end of life catheterisation may include:

  • Management or prevention of wound damage, for example sacral pressure ulcers and or fungating wounds, or discomfort of the anus, perineum, vulva or penis
  • Painful physical movements due to frequent changes of bedlinen caused by incontinence
  • Pain or difficulty for female patients getting in and out of bed to use a commode
  • Urinary incontinence associated with obstruction
  • Urinary retention/distended bladder – the commonest cause of retention in the terminal phase is constipation caused by morphine

Consent to catheterise should be given by the medical professional responsible for that patient’s care. If the indwelling catheter increases a dying patient’s pain or restlessness, it should be removed.

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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Readers' comments (1)

  • How is the problem solved when the dying person has a blocked catheter during the night and the only thing to do is send this person to hospital ? this question is based around a client being cared for in their own home. Its a very sad scenario.

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