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Covid-19 HSE Clinical Guidance and Evidence

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Non-Pharmacological Care

Non-Pharmacological Care in the Last Hours or Days of Life (CD19-072 001 / 15.04.20)


  • Adherence to guideline recommendations will not ensure a successful outcome in every case. For more detailed guidance, suggest https://www.palliativecareguidelines.scot.nhs.uk AND/OR contact specialist palliative care team for advice.
  • It is the responsibility of all professionals to exercise clinical judgement in the management of individual patients. In the event of a patient unexpectedly stabilising / improving, reconsider the diagnosis of ‘dying’.
  • This guideline is for all healthcare professionals.
  • This guidance document was developed by the National Palliative Care Clinical Programme in accordance with HPSC guidance, https://www.hpsc.ie
     
Shift to focus on comfort care

General considerations

Discontinue unnecessary prescriptions, monitoring activities, and procedures. Consider stopping anything that doesn’t focus on comfort and alleviating symptoms/distress unless there is a good reason to continue it. Common areas that require review include:

  • I/V fluids, antibiotics, s/c heparin, insulin, enteral nutrition and TPN.
  • O2 masks and nasal prongs unless clear symptom benefit.
  • Stop blood and radiological tests.
  • Stop monitoring vital signs including oxygen saturation, fluid balance etc.
  • Deactivate ICDs and remove cardiac monitors.
  • Ensure DNACPR order signed / EWS stopped.
     
Environment

General Physical environment:

  • Where possible a quiet, peaceful environment is preferable.
  • Minimise loud noises and bright lights (delirium is not uncommon in last days/hours of life).

Bedside environment:

  • Calm, reassuring bedside presence.
  • Inform patient (even if unresponsive) who you are and what you are doing or about to do.
     
Psychological / Spiritual care

Insight:

  • Where appropriate, patient insight should be assessed and fears / wishes explored.
  • Consider if formal pastoral care support needed / rituals which are important to patient and family.
     
Physical care

Respiratory Secretions:

  • Explain to family and reassure that it may not represent discomfort.
  • Re-positioning patient on side may help.
  • Assess need for pharmacological intervention.
  • Suctioning is rarely useful or indicated in last hours/days of life and has all the associated infection risks of an aerosol-generating procedure (AGP). It should be avoided where possible.
  • For AGP and PPE guidance refer to https://www.hpsc.ie

Bowel care:

  • Invasive procedures for bowel care rarely needed when imminently dying.

Urinary care:

  • Catheterise if in urinary retention or incontinence likely to cause loss of skin integrity or aids the general comfort level of patient.

Mouth care:

  • Ensure mouth and lips are clean and moist.
  • Regularly moisten oral cavity with sips of water /water-based gel when able to swallow or with moist mouth sponge when unable.

Food and fluid:

  • Continue to offer variety of soft foods / sips of water through teaspoon / straw while conscious, able to sit up, and as appropriate.
  • Accept when patient unable/declines to take as this is natural part of dying. Never force.

General comfort:

  • Repositioning, regular turning 2 – 4 hourly to prevent pressure sores.
  • Regular skin and eye care.
     
Social / Family care

(Physical presence will depend on infection control protocols)

  • Explain to family that death is approaching in sensitive yet clear way.
  • Explain focus of care is on comfort and dignity.
  • Explain the expected changes in physical and cognitive function as this will relieve distress for family.
  • Check previous experiences and understanding of dying as it may allow you to correct misunderstandings.
     
Questions family members often ask
  • How long has (s) he got?
    “We can’t be certain, but it’s likely to be within a few hours or days at most. What would you like for her?”
     
  • Can (s)he still hear?
    “We don’t know for sure but if you would like to say something, now is the time “
     
  • How will you know if (s)he has pain?
    “We will watch carefully for signs of distress. We will give whatever medication is needed to keep him/her pain free and comfortable”
     
  • Is (s)he dying of dehydration or starvation?
    “At this time, all of the vital organs including his heart and kidneys are shutting down. His/her body cannot cope with food or fluid right now.”

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