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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 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,
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.

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


  • 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

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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