liverpool care pathway for use in a community hospital or care home final rev aug10
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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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Worcestershire Primary Care NHS Trust 2010 Page 3 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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
Please attach patient sticker here or record:
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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Worcestershire Primary Care NHS Trust 2010 Page 7 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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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Worcestershire Primary Care NHS Trust 2010 Page 8 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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
Consider need for positional change
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
Consider need for positional change
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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Worcestershire Primary Care NHS Trust 2010 Page 9 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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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Worcestershire Primary Care NHS Trust 2010 Page 11 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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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Worcestershire Primary Care NHS Trust 2010 Page 12 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
Name:...
Unit No:
D.O.B: .//...
Male Female
Date: ....................................................
Variance analysis
What Variance occurred & why? Action Taken Outcome
Signature.
Date/Time.
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Worcestershire Primary Care NHS Trust 2010 Page 13 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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.
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Date/Time.
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Date/Time.
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Worcestershire Primary Care NHS Trust 2010 Page 14 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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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Worcestershire Primary Care NHS Trust 2010 Page 15 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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
SUPPORTIVE INFORMATION:
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.
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
These guidelines are produced according to local policy & procedure
Present Absent
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Worcestershire Primary Care NHS Trust 2010 Page 16 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
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
SUPPORTIVE INFORMATION:
If symptoms persist contact the Palliative Care Team
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
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
Present Absent
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Worcestershire Primary Care NHS Trust 2010 Page 17 of 18Care Pathway for Dying Phase Final Version Revised August 2010
Please attach patient sticker here or record:
Name:...
Unit No:
D.O.B: .//...
Male Female
N a u s ea a n d v o m i t i n g
SUPPORTIVE INFORMATION:
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.
These guidelines are produced according to local policy & procedure
CSCI = Continuous Subcutaneous Infusion
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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