End of Life Care

When patients are admitted to the ward, in addition to normal contact information, relatives should be asked to identify: a primary point of contact for clinical staff to call, a secondary point of contact for clinical staff to call should the primary contact point fail. Any times of day that they would like to be contacted or videoconferencing abilities may also be worth noting.

With some cases of Covid-19 the person may become ill and deteriorate quite quickly so the opportunity for discussion and involving them in decision making may be limited or lost. Families and those close to them may be shocked by the suddenness of these developments and may themselves be ill and / or required to self-isolate. There may be multiple members of the family ill at the same time. But as far as possible it remains important to offer these conversations.

Being kept honestly informed helps to reduce anxiety, even if the health care professionals do not have all the answers and even if the conversations need to be conducted behind PPE or by telephone or by using other technology solutions.

Key points to consider when discussing ceilings of treatment (SPIKES):

• Setting / situation: read clinical records, ensure privacy, no interruptions
• Perception: what do they know already?; no assumptions
• Invitation: how much do they want to know?
• Knowledge: explain the situation; avoid jargon; take it slow
• Empathy: even if busy, show that you care
• Summary / strategy: summarise what you’ve said; explain next steps

“Advance Care Planning (ACP) is the term used to describe the conversation between people, their families and carers and those looking after them about their future wishes and priorities for care.” - Gold Standards Framework.

Such conversations, which constitute advance care planning, are useful during normal times, but even more so during the COVID-19 outbreak. Honest conversations about goals of care and treatment escalation planning should be initiated as early as is practicable so that a personalised care and support plan can be developed and documented.

Families and those close to the person should be involved in these discussions as far as possible and in line with the person’s wishes. This is standard good practice in palliative and end of life care.

Further information is available from NICE

A Do Not Attempt Resuscitation (DNACPR) decision applies solely to Cardiopulmonary Resuscitation (CPR). All other treatment and care should be continued and not be influenced by the DNACPR decision.

Opportunities to discuss Do Not Attempt Resuscitation (DNAR) with the person or their advocate/family if they lack capacity are important and should be initiated early on. Where appropriate, regular reviews of DNACPR status should take place within the MDT. Due to Covid-19 there is an increased need to be proactive to ensure these conversations take place early within our services.

In May 2019 the National Medical Director, Professor Stephen Powis, wrote with regard to Learning disability, death certification and DNACPR orders, emphasising that:

‘The terms “learning disability” and “Down’s syndrome” should never be a reason for issuing a DNACPR order or be used to describe the underlying, or only, cause of death … Learning disabilities are not fatal conditions.’

Treatment decisions should not be made on the basis of the presence of learning disability and / or autism alone.

Further information about DNACPR’s are available within the organisations respective Resuscitation Policies:

• Resus Policy for former BCPFT staff
• Resus Policy for former DWMH staff

Individuals with a rapidly deteriorating condition that may be entering a terminal phase, may require ‘fast tracking’ for immediate provision of NHS Continuing Healthcare. Where appropriate the MDT should consider a ‘fast-track’ CHC assessment, to transfer the patient to a more specialist and appropriate placement or home for end of life care. Further information is available on the CHC website here.

If the individual is detained under the MHA, the RC must consider whether it is appropriate to continue with the detention.

Three triggers that suggest that patients are nearing the end of life are:

1. The Surprise Question: 'Would you be surprised if this patient were to die in the next few months, weeks, days'?
2. General indicators of decline - deterioration, increasing need or choice for no further active care.
3. Specific clinical indicators related to certain conditions. 

Patients that have Covid-19 may have a rapid deterioration in their physical health. The terminal phase of dying is defined as ‘The last days or hours of a person's life is often called the terminal phase or dying phase’ (Marie Curie, 2018). Everyone’s experience of dying is different, and some people will die suddenly or unexpectedly. But in most cases, there are some signs that can help you to recognise when someone is entering the terminal phase. These include:

People who may benefit from specialist palliative care include those whose symptoms cannot be managed in a timely way by their usual care team. Specialist palliative care should be available on the basis of need, not diagnosis.

The Trust has arrangements in place for staff to access specialist palliative care services for a range of specialist advice, support and care during Covid-19.

Walsall

Palliative Care Team

‘Working hours’ 0900-1630hrs: 01922 602620

Out of hours 16.30-0900hrs: 01922 721721 (WMH switch)

District Nurse Team

North locality (Bloxwich)

‘Working hours’ 0800-1800hrs: 01922 605750

Out of hours 1800-0800hrs, bank holidays and weekends: 01922 721721 (WMH switch)

Email: palliativecns.team@nhs.net for guidance for support. 

Dudley

General Advice (During Covid-19 only)

The Mary Stevens Hospice is able to offer palliative care advice to healthcare professionals: 7 days a week between the hours of 8am-4pm by calling 01384-445417 or emailing supporthub@marystevenshospice.co.uk

24/7 End of Life Rapid Response Team

Last 5 days of life care.

01384 321929 (Triage line).

District Nurses

Single Point of Access: 01384 321600

Out of Hours: 01384 456111

Specialist Palliative Care Team

Referral form below. Patient must have a clinical specialist need.

Referrals (urgent: response within 24hrs) email referral form and phone:

Weekdays 01384 321523 (9am-5pm)

Weekends:  01384 321600 option 1 (9am-5pm)

Referrals (non-urgent: response within 5 days)

Email referral form to: dgft.dmscah@nhs.net

Referral form available here 

Wolverhampton

Compton Hospice

4 Compton Road West,

Wolverhampton,

WV3 9DH

Tel: 0845 225 5497 In working hours please ask for 'medical secretaries', for out of hours your call will be transferred to a health care professional

https://www.compton-hospice.org.uk/

Sandwell

Compton Hospice

263 Duchess Parade

High Street

West Bromwich

West Midlands

B70 7NN

Tel: 0121 553 2061 or 0845 225 5497 In working hours please ask for 'medical secretaries', for out of hours your call will be transferred to a health care professional

https://www.compton-hospice.org.uk/

Click here to read the latest guidance on visiting a patient with Covid19.

Non-Pharmacological Interventions

Generally, non-drug approaches are preferred, particularly in mild to moderate disease. Further information is available here and contains Covid-19 specific interventions for consideration by staff. This includes guidance on:

• Breathlessness
• Cough
• Delirium
• Fever

Pharmacological Interventions

Patients should receive all appropriate supportive treatments and correctable causes of the symptoms considered and managed appropriately. Examples include:

• Antibiotic treatment for a superadded bacterial infection may improve fever, cough, breathlessness and delirium
• Optimising treatment of comorbidities (e.g. chronic obstructive airways disease, heart failure) may improve cough and breathlessness.

Best practice guidance is that in general all medication should be reviewed and rationalised by the multidisciplinary team regularly. Prescribing should be based on the most up to date evidence based prescribing advice reflected in the respective area’s joint formularies. Prescribing at the end of life can include, but not be limited to, pain, nausea and vomiting, breathlessness or infections. Practitioners are reminded that they should only prescribe treatments that are within their routine scope of practice and where they can evidence that they have the most up to date knowledge skills and competency to do so. 

In general where specific end of life care and treatment is needed this should be provided under the direct supervision and with operational support from appropriate palliative specialists / teams. For the most up to date evidence based prescribing advice, guidance and how to access specialist prescribing advice locally please see your relevant local area joint formulary. The west midlands palliative care physician’s guidelines also provide a useful and regional resource.

Patients should not be left in pain whilst advice is sought or in urgent situations.

Information on infection control for the care for the deceased patient during Covid-19. There is also further guidance within infection control policies for non-covid-19 deceased patients.

Guidance around the death of an inpatient is detailed within the following policies:

Former BCPFT staff: ‘Death of an Adult Service User Policy’

Former DWMH staff: ‘Procedural Guideline for management of the death of an Inpatient’

• Covid-19 Specific EOL Guidance (APM):
  • The Association for Palliative Medicine of Great Britain and Ireland (APM) have produced helpful guidance, including care of the Covid-19 actively dying patient pharmacological and non-pharmacological interventions. It is a live document available from here.

• End of Life Care E-Learning:
  • There are useful modules produced by HEE, including e-learning, information sheets and videos on subjects around end of life. As these discussions are vital, would be useful for both medical and registered nursing staff.
  • DNAR discussions
  • Advance Care Planning: how I have the conversation
  • Breaking bad news  
  • Ceilings of Treatment  
  • Emotional Support & signposting
  • Website: http://www.e-lfh.org.uk/coronavirus
  • This is found: Full catalogue > Coronavirus (COVID-19) > End of Life Care COVID-19

• Advance Care Planning:  ‘Five simple steps to ACP’ or as a YouTube video here. 
• The End of Life Care Library - A wealth of resources for EOL care, discussions and Covid-19 specific guidance.
• NICE Guidelines: Management of EOL care for Covid-19
• Leadership Alliance for the Care of Dying People One Chance to get it Right.

Compton Hospice are now providing services for people that are bereaved, that may feel isolated and lonely or may be experiencing loss and grief. The two services available are:

• A Telephone Befriending Service
• Bereavement Information Hubs