Covid-19 HSE Clinical Guidance and Evidence

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Recognising Dying in the Last Hours or Days of Life (CD19-117 001 / 27.04.20)

• Recognising that a person is dying

• Communication

• Involve

• Signs and symptoms

• Support

• Do

• 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.
• This guidance is for health care professionals to support patients who are in the last hours or days of life during the Covid-19 pandemic.
• This guidance document was developed by the National Palliative Care Clinical Programme in accordance with HPSC guidance, https://www.hpsc.ie
   

​Recognising that a person is dying

• Imminently dying is a term used to describe patients who are rapidly approaching end of life. The prognosis is expected to be some hours or short days and the patient is likely to be unresponsive. A senior and experienced Clinician and Senior Nurse, as part of a team, will determine that there is no prospect of achieving reversibility and now the focus is exclusively on ensuring comfort.
• The diagnosis of dying can be challenging and if any doubt persists the team should be open to reviewing it at any stage.
   

Communication

• Clear and sensitive communication should take place between staff, the person who is dying and those identified as important to them. A diagnosis of dying must be shared sensitively with close family as appropriate. Once a diagnosis of dying is made the decision must be recorded in the clinical record and disseminated with the multidisciplinary team
   

Involve

• The dying person and those identified as important to them are involved in decisions about care to the extent that the dying person wishes.
   

​Signs and symptoms

• Diagnosing dying is not easy, there is no one feature that can diagnose dying, a range of symptoms may be present, but varies from individual to individual.
• Consider the response to supportive therapies and if there is a meaningful and sustained response to supportive treatments.
• Predicting when somebody is going to die is often complex.
• Signs of approaching death are picked up by the day-to-day assessment of deterioration, some but not all of the signs listed may occur:
  • Diminished intake of food and fluids
  • Difficulty swallowing medications
  • Decreased level of consciousness
  • Bed-bound/full nursing assistance required
  • Apnoeic periods
  • Peripheral cyanosis
  • Cheyne-Stokes respirations
  • Audible respiratory secretions
  • Impalpable radial artery
  • Mandibular movement on respiration
  • Oliguria
• Should symptoms develop suddenly, it is important to exclude a reversible cause of the deterioration such as infection, hypercalcaemia or adverse effects of medication changes.
   

Support

• The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible. It is important to be sensitive to the patient and/or family’s beliefs. If in doubt, ask a family member to avoid offense.
• Clear guidance (based on visiting policy currently in place) should be offered to the family. Visits should be facilitated as per the guidance.
   

Do

• An individual plan of care is agreed, coordinated and delivered with compassion.
• There can be challenges and difficulties but reassure families that the exclusive focus is on comfort measures.
• In the event of a patient unexpectedly stabilising / improving, reconsider the diagnosis of ‘dying’.