liverpool care pathway for use in a community hospital or care home final rev aug10

8/13/2019 Liverpool Care Pathway for Use in a Community Hospital or Care Home Final Rev Aug10

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Worcestershire Primary Care NHS Trust 2010 Page 1 of 18Care Pathway for Dying Phase Final Version Revised August 2010

Care Pathway for the Dying Phase

For Use in a Community Hospital or Care Home

DO NOT PUT PATIENT ON THIS PATHWAY UNLESSAl l possible reversible causes for current condi tion have been considered

(Unless an advanced care plan is in place which specifies that life-prolonging

measures are not w ished by the patient and/or clinically inappropriate)AND

The multi-professional team has agreed that the patient is dying, and two of the fol lowing may apply:

The patient is bedbound Semi-comatose

Only able to take sips of fluids No longer able to take tablets

Guidelines referred to when developing this Care Pathway

1. Guidelines for the Use of Drugs in Symptom Control West Midlands Palliative Care Physicians. 4th

Edition2007

2. Care of the Dying Pathway (Hospital) Liverpool Care Pathway (version 11) (2008)

3. Worcestershire Do Not Attempt Resuscitation Policy (DNAR) 2007

4. Ellershaw JE, Wilkinson S (2003) Care of the dying: A pathway to excellence. Oxford: Oxford University Press.

PREFERRED PLACE OF CARE FOR DYING PHASE

Home

Hospice

Hospital

If preferred place of care is hospice or hospital, please document inthe multidisciplinary progress notes why care is being provided athome.

This Care Pathway has been developed by a multidisciplinary team. It is intended as a GUIDE to careand treatment, and an aid to documenting patient and family care.

All healthcare professionals are of course free to exercise their own professional judgment when usingthis Pathway. However if the Care Pathway is varied from for any reason, the reason for variation and

subsequent action taken must be documented on the multidisciplinary progress notes.

If you have any problems completing the pathway please contact a member of your local specialistpalliative care team.

Please attach patient sticker here or record:

Name:...

Unit No:

D.O.B: .//...

Male Female

Consultant: ... Ward: ......


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Name:...

Unit No:

D.O.B: .//...

Male Female

Consultant: ... Ward: ......

Consultant/GP:....................................... Named nurse:........................................... Ward: ................

Al l personnel completing the care pathway please sign below

Name (print) Full signature Initials Professional tit le Date


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ADD OWN ORGANISATIONAL LOGO HERE

Worcestershire Primary NHS Trust 2010 Page 5 of 18Care Pathway for Dying Phase Final Version Revised August 2010


Name:...

Unit No:

D.O.B: .//...

Male Female

Section 1 Initial assessment - continued Sign/DesigDate/Time

Psychological/

InsightGoal 4: Ability to communicate in English assessed as adequate

a) Patient Yes No Comatosed

b) Family/other ................................. .Yes No

Goal 5: Insight into condition assessed

Aware of diagnosis a) Patient Yes No Comatosed

b) Family/other Yes No

Recognition of dying c) Patient Yes No Comatosed

d) Family/other Yes No

Religious/

Spiritualsupport

Goal 6: Religious/spiritual needs assessed

a) with Patient Yes NoComatosed

b) with Family/other Yes No

Patient/other may be anxious for self/others

Consider specific cultural needs

Consider support of Familys Faith Leader eg. Vicar, Priest, Iman, Rabbi

Religious Tradition identified, Yes No N/A

if yes specify:

Support of Chaplaincy Team offered Yes No

In-house support Tel/bleep no:

Name: . Date/time:

External support Tel/bleep no:

Name: .. Date/time:

Comments (Special needs now, at time of impending death, at death & after death identified)

Communication

with

family/other

Goal 7:

Identify how family/other are to be informed of patients impending death

Yes No

At any time Not at night-time Stay overnight at Hospital

Primary contact name:.........................................................................................................

Relationship to patient:............................................. Tel no: .............................................

Secondary contact: .............................................................................................................

Tel no:...............................................................................................................................

Goal 8: Family/other given hospital information on:- Yes No

Facilities leaflet available to address:

Car parking; Accommodation; Beverage facilities; Payphones; Washrooms & toilet facilities on

the ward; Visiting times; Any other relevant information.Communication

with primary

health careteam

Goal 9: G.P. Practice is aware of patients condition Yes No

G.P. Practice to be contacted if unaware patient is dying, message can be left with the

receptionist

Summary Goal 10: Plan of care explained & discussed with:

a) Patient Yes No Comatosed

b) Family/other ................................. ..Yes NoGoal 11: Family/other express understanding of planned care Yes No

Family/other aware that the planned care is now focused on care of the dying & their concerns

are identified & documented.

The LCP document may be discussed as appropriate

If you have charted No against any goal so far, please complete variance sheet on the back page.

Health Professional signature: ......................................... Title: ....................... ....

Date: ............................................................................. Time:.


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Name:...

Unit No:

D.O.B: .//...

Male FemaleDate: ....................................................

Codes (please enter in columns) A= Achieved V=Variance 0 8 : 0 0 2 0 : 0 0

M o b i l i t y / P r e ss u r e

a r e a c a r eGoal: Patient is comfortable and in a safe environment

Clinical assessment of:Skin integrity

Need for positional change

Need for special mattress

Personal hygiene, bed bath, eye care needs

B ow e l c a r e Goal: Patient is not agitated or distressed due to constipation or diarrhoea

P a t i e n t

Goal: Patient becomes aware of the situation as appropriate

Patient is informed of procedures Touch, verbal communication is continued

P s y c h o l o g i ca l /

I n s i g h t su p p o r t

Fa m i l y / o t h e r

Goal: Family/other are prepared for the patients imminent death with the aim

of achieving peace of mind and acceptance

Check understanding of nominated family/others / younger adults / children Check understanding of other family/others not present at initial assessment Ensure recognition that patient is dying & of the measures taken to maintain comfort Psychological support offered

R e li g io u s /

S p i r i t u a l s u p p o r tGoal: Appropriate religious/spiritual support has been given

Patient/other may be anxious for self/others

Consider spiritual/faith needs Involve faith leaders as appropriate

Ca r e o f t h e f am i l y

/ o t h e r sGoal: The needs of those attending the patient are accommodated

Consider health needs & social support.Ensure awareness of ward facilities

S i g n a t u r e

Health Professional

Signature Early: ................................................. Late: .............................................. .. Night: ...............................


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Name:...

Unit No:

D.O.B: .//...

Male FemaleDate.

Codes (please enter in columns) A= Achieved V=Variance (not a signature)

Se c t i o n 2 P at i en t p r o b l e m / f o c u s 0 4 : 0 0 0 8 : 0 0 1 2 : 0 0 1 6 : 0 0 2 0 : 0 0 2 4 : 0 0

Ongoing assessment

Pa i n

Goal: Patient is pain free

Verbalised by patient if conscious

Pain free on movement

Appears peaceful

Consider need for positional change

A g i t a t i o n

Goal: Patient is not agitated

Patient does not display signs of delirium, terminal anguish,

restlessness (thrashing, plucking, twitching)

Exclude retention of urine as cause


R e s p ir a t o r y t r a c t s e c r e t i o n s

Goal: Excessive secretions are not a problem

Medication to be given as soon as symptoms arise


Symptom discussed with family/other

N a u s e a & v o m i t i n g

Goal: Patient does not feel nauseous or vomits

Patient verbalises if conscious

D y s p n o e a

Goal: Breathlessness is not distressing for patient

Patient verbalises if conscious.

Consider need for positional change.

Other symptoms (e.g. oedema, itch)

.................................................

T r e a t m e n t / p r o c e d u r e s

M o u t h c a r e

Goal: Mouth is moist and clean

Mouth care assessment at least4 hourly

Frequency of mouth care depends on individual need Family/other involved in care given

M i c t u r i t i o n d i f f i c u l t i e s

Goal: Patient is comfortable

Urinary catheter if in retention

Urinary catheter or pads, if general weakness creates

incontinence

Me d i c a t i o n (If medication not required please record as

N/A)

Goal: All medication is given safely & accurately

If syringe driver in progress check at least 4 hourly

according to monitoring sheet

S i g n a t u r e

Repeat this page 24 hrly. Spare copies on Ward

If you have charted V against any goal so far, please complete variance sheet on the back page


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Name:...

Unit No:

D.O.B: .//...

Male Female

Date: ....................................................

Codes (please enter in columns) A= Achieved V=Variance 0 8 : 0 0 2 0 : 0 0

M o b i l it y / P r e ss u r e

a r e a c a r eGoal: Patient is comfortable and in a safe environment

Clinical assessment of:

Skin integrity

Need for positional change

Need for special mattress

Personal hygiene, bed bath, eye care needs

B ow e l c a r e Goal: Patient is not agitated or distressed due to constipation or diarrhoea

P a t i e n t

Goal: Patient becomes aware of the situation as appropriate

Patient is informed of procedures

Touch, verbal communication is continued

P s y ch o l o g ic a l/

I n s i g h t su p p o r t

Fa m i l y / o t h e r

Goal: Family/other are prepared for the patients imminent death with the aim

of achieving peace of mind and acceptance

Check understanding of nominated family/others / younger adults / children

Check understanding of other family/others not present at initial assessment

Ensure recognition that patient is dying & of the measures taken to maintain comfort

Chaplaincy Teamsupport offered

R e li g i ou s /

S p i r i t u a l s u p p o r tGoal: Appropriate religious/spiritual support has been given

Patient/other may be anxious for self/others Support of Chaplaincy Team may be helpful

Consider cultural needs

C ar e o f t h e f am i l y

/ o t h e r sGoal: The needs of those attending the patient are accommodated

Consider health needs & social support.

Ensure awareness of ward facilities

S i g n a t u r e


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Name:...

Unit No:

D.O.B: .//...

Male Female

Date: ....................................................

SECTION 3: Confirmation of death

Date of death:....................................................................................... Time of death: ...................

Persons present: ...............................................................................................................................

Notes:...............................................................................................................................................

........................................................................................................................................................

Signature: ........................................................................................... Time of confirmation: ..........

Goal 12: GP Practice contacted re patients death Date __/__/__ Yes No

If out of hours contact on next working day

Goal 13: Procedures for laying out followed according to hospital policy Yes No

Carry out specific religious / spiritual / cultural needs - requests

Goal 14: Procedure following death discussed or carried out YesNo

Check for the following: Explain mortuary viewing as appropriate

Family aware cardiac devices (ICDs) or pacemaker must be removed prior to cremation

Post mortem discussed as appropriate.

Input patients death on hospital computer

Goal 15: Family/other given information on hospital procedures Yes No

Hospital information booklet given to family/other about necessary legal tasks

Relatives/other informed to ring Bereavement Office after 10.00am on next

working day to make an appointment to collect death certificate

Goal 16:Hospital policy followed for patients valuables & belongings Yes No

Belongings and valuables are signed for by identified person

Property packed for collection.

Valuables listed and stored safely

Goal 17:Necessary documentation & advice is given to the appropriate person Yes

No

What to do after death booklet given (DHSS)

Goal 18: Bereavement leaflet given YesNo

Information leaflet on grieving and local support given

If you have charted No against any goal so far, please complete variance sheet at the back

of the pathway before signing below

Health Professional

signature:..................................................................... Date: ..................................................

Ca r e a f t e r

d e a t h

Have you completed the last 4 & 12 hourly observation

Please contact the Palliative Care Team to inform them that this patient was on a pathway.


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Name:...

Unit No:

D.O.B: .//...

Male Female

Date: ....................................................

Variance analysis

What Variance occurred & why? Action Taken Outcome

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.


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Name:...

Unit No:

D.O.B: .//...

Male Female

Date: ....................................................

Variance analysis

What Variance occurred & why? Action Taken Outcome

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.

Signature.

Date/Time.


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Name:...

Unit No:

D.O.B: .//...

Male Female

Patient is in pain Patients pain is controlled

Is patient already taking oral morphine? Is patient already taking oral morphine?

YES NO YES NO

1.Give MORPHINE Sulphate

Injection

2.5mg - 5mg s/c

Repeat after 1 hour if

necessary

1. Prescribe MORPHINE

2.5mg- 5mg s/c hourly

prn

2. After 24hrs review

medication, if three or

more doses required prn

then consider a CSCI via

syringe driver over 24hrs.

2. After 24hrs review

medication, if three or

more doses required prn

then consider a syringe

driver over 24hrs

SUPPORTIVE INFORMATION:

To convert from other strong opioids contact Palliative Care Team for further advice & support asneeded

If symptoms persist contact the Palliative Care Team

Anticipatory prescribing in this manner will ensure that in the last hours / days of lifethere is no delay responding to a symptom if it occurs.

These guidelines are produced according to local policy & procedure

CSCI = Continuous Subcutaneous Infusion

1.Convert patient from oral

morphine to a 24hr s/c

infusion of MORPHINE

Sulphate Injection via

syringe driver

(divide the total daily dose

of morphine by 2

e.g. MST 30mg bd orally

= MORPHINE Sulphate

Injection 30mgs/24hrs by

CSCI)

2. Give prn dose of

MORPHINE Sulphate

Injection which should be

1/6 of 24hr dose in driver

e.g. MORPHINE Sulphate

Injection 60mg/24hrs

CSCI via driver will

require MORPHINE

Sulphate Injection 10mg

s/c prn Repeat after 1

hour if necessary

1.Convert patient from oral

morphine to a 24hr s/c

infusion of MORPHINE

Sulphate Injection via

syringe driver

(divide the total daily dose

of morphine by 2

e.g. MST 30mg bd orally

= MORPHINE Sulphate

Injection 30mgs/24hrs by

CSCI)

2. Prescribe prn dose of

MORPHINE Sulphate

Injection which should be

1/6 of 24hr dose in driver

e.g. MORPHINE Sulphate

Injection 60mg/24hrs

CSCI via driver will

require MORPHINE

Sulphate Injection 10mg

s/c prn Repeated after 1

hour if necessary

P a i n


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Name:...

Unit No:

D.O.B: .//...

Male Female

1. Give MIDAZOLAM 2.5 - 5mg s/cRepeat in 30 minutes if necessary

1. Prescribe MIDAZOLAM 2.5 - 5mgs/c prn

Repeated in 30 minutes if

necessary

2. Review the required

medication after 24hrs or

earlier if clinically

indicated, if three or more

prn doses have been

required then consider a

CSCI via syringe driver

2. If three or more doses required prn

before next review, consider a CSCI

via syringe driver

3. If Midazolam ineffective

as an anxiolytic consider

alternatives as below

T e r m i n a l r e s t l e ss n e s s a n d a g i t a t i o n




Alternative anxiolytics include Haloperidol 1mg-5mg s/c hourly as required, max dose20mg/24hrs and Levomepromazine 12.5mg-25mg hourly as required, max dose150mg/24hrs


Present Absent


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Name:...

Unit No:

D.O.B: .//...

Male Female

1. Give HYOSCINE HYDROBROMIDE

0.4mg s/c. Consider starting a CSCI

via syringe driver 1.2mg/24hrs

1. Prescribe HYOSCINE

HYDROBROMIDE 0.4mg s/c

2 hourly prn

Max dose/24hrs 2.4mg

2. Repeat doses as required 2 hourly,

Max dose/24hrs 2.4mg2. If two or more doses of prn

HYOSCINE HYDROBROMIDE

required and effective then consider

a CSCI of 1.2mg-2.4mg/24hrs via

syringe driver

3. Consider increase to 2.4mg/24hrs

if symptoms persist and prn doses

effective

R es p i r a t o r y t r a c t s ec r e t i o n s



Alternatives include: Glycopyrronium 0.4mg s/c 2 hourly prn, max dose 2.4mg/24hrsor Hyoscine Butylbromide 20mg s/c hourly prn, max dose 180mg/24hrs




Present Absent


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Name:...

Unit No:

D.O.B: .//...

Male Female

N a u s ea a n d v o m i t i n g


N.B Always use water for injection when making up Cyclizine.

If symptoms persist contact the palliative Care Team.

Cyclizine is not recommended in patients with heart failure.

Cyclizine injection is not compatible with Oxycodone injection and HyoscineButylbromide Injection

Alternative antiemetics include:-

H a l o p e r id o l s / c 1 m g 2 . 5 m g 2 h o u r l y p r n ( 2 . 5 m g1 0m g v i a sy r i n g e D r i v e r o v e r 2 4 h r s )

L ev o m e p r o m a z in e s / c 5 m g 2 h o u r l y p r n ( 5 m g 2 5 m g v i a sy r i n g e Dr i v er o v e r 2 4 h r s )

Anticipatory prescribing in this manner will ensure that in the last hours / days oflife there is no delay responding to a symptom if it occurs.



1. Prescribe Cyclizine 50mgs S/C

2 hourly prnMax dose 150mg/24hrs

Present Absent

2. If two or more doses required prn andeffective, consider giving a CSCI of100mg to 150mg/24hrs via syringe

driver

1. Give Cyclizine 50mgs S/C

Repeat 2 hourly prnMax dose 150mg/24hrs

2. Review dosage after 24 hrs. If two ormore prn doses given and effective,then consider use of a syringe driver

Cyclizine 100mg 150mgs CSCI via a

syringe driver over 24hrs


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liverpool care pathway for use in a community hospital or care home final rev aug10

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