Covid-19 HSE Clinical Guidance and Evidence

Palliative Care - Homepage

Older Persons - Homepage

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

• Shift to focus on comfort care

• Environment

• Psychological / Spiritual care

• Physical care

• Social / Family care

• Questions family members often ask

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• 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.”