People should be able to die in the place of their choice. New guidance gives practical advice on how to ensure patients’ preferred priorities are achieved
Anita Hayes, RGN, DN, RCNT, is deputy director, National End of Life Care Programme
New guidance provides nurses working in acute trusts with practical advice to help them ensure more people achieve “a good death” (National End of Life Care Programme, 2010). It is aimed at helping more people die in the place of their choice without unnecessary interventions or emergency hospital admission.
The guide emphasises high quality end of life care (EoLC) is built around early identification that a patient is nearing the end of life, holistic assessment, care planning, advance care planning (ACP), coordination of care and effective discharge policies and procedures. This includes working in partnership with colleagues in primary care, the voluntary sector and social care.
The guide sets out points for each of the six steps along the EoLC pathway that nurses can consider in relation to their area of practice.
Step 1: Discussions as the end of life nears
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Nurses should be able to identify that a patient might be nearing the end of life and recognise cues that they are ready to have a discussion about changes in their condition and future care. They should listen to and support patients as they talk about their preferred priorities and preferences for care and record and share this information with other members of the care team. Training in communication skills will help nurses feel confident to have such discussions.
Nurses and colleagues should ask whether they would be surprised if the patient were to die in the next year - the so-called “surprise question” - and what they are trying to achieve with a specific intervention.
Step 2: Assessment, care planning and review
Each team should identify who has the skills and knowledge to assess patients - and carers where appropriate. The holistic assessment should address patients’ physical needs and any issues relating to their psychological and spiritual needs. It should also address practical issues such as their financial position.
However, assessments should be concerns led, that is, shaped by patients, and reviewed as the patient’s condition changes and results shared (with consent) with relevant partners. Holistic assessment will shape care plans and may lead to a discussion about ACP and patients’ preferred priorities and preferences for future care. Nurses should also consult the NEoLCP’s recent guidance on holistic common assessment at tinyurl.com/holistic-common.
Step 3: Coordinating care
Sharing information and planning care with colleagues in the hospital trust and primary and social care agencies is crucial. This means good communication with the multidisciplinary team (many trusts invite partner organisations to meetings). Staff should be aware of key contacts for patients in partner organisations; a key worker can act as a link between organisations and support care coordination.
The guide includes examples of when nurses have taken the lead in working with partners in primary and social care to ensure rapid discharge home to die where that is the patient’s choice. It highlights good practice where trusts have designated discharge nurses working with those partners to ensure that the equipment and professional support needed for patients to be cared for adequately at home are in place before they are discharged from hospital.
Step 4: Delivering high quality care
The guide emphasises the importance of the environment in which patients are cared for - particularly in relation to privacy and dignity. It also urges nurses and other clinicians to access relevant training - for example on communication skills - and to recognise their own limitations in particular situations. Often it will be appropriate to call in colleagues with particular expertise.
Step 5: Care in the last days of life
The guide advises nurses to discuss with both patients (where possible) and their families changes that might occur as death approaches. It also supports the use of a recognised EoLC tool such as the Liverpool Care Pathway. It stresses that patients (where possible) and families should be involved in the decision to place them on the pathway as well as decisions about stopping or avoiding certain treatments. This, the guide notes, means staff should be trained and supported to use such tools properly.
Step 6: Care after death
The guide highlights the importance of staff communicating sensitively with the bereaved. This includes being aware of cultural and religious differences surrounding death. Nurses involved in caring for people approaching the end of life should be aware of the location of the bereavement suite and the services it provides.
Nurses have a vital role in supporting patients to achieve their preferred priorities and place of care. They can coordinate services with colleagues in the community and in social care, introduce ACP and arrange rapid discharge home to die. This will improve the quality of end of life care and support for families while helping to reduce unnecessary deaths in hospital.
National End of Life Care Programme (2010) The Route to Success in End of Life Care - Achieving Quality in Acute Hospitals. Leicester: NEoLCP.