Physical care at the end of life
1
Introduction and note of caution
• Welcome
• Note of caution
o Talking about last days of life is hard – professionally as well as personally
o This session is designed to help you so you can help your patients and
those important to them
o If you feel upset or emotional that is okay – you are encouraged to stay
and we will help but if you must leave please speak to a friend or
colleague so you have some support
2
Objectives
• Describe how to provide respectful care for a dying person:
o maintaining dignity
o Understand the patient who is dying may still be able to hear, even if they
are unable to respond
• Describe the key principles of gentle, sensitive care including:
o repositioning, personal hygiene, skin care, continence care, monitoring
and observation, good oral care
• Explain how to support family with personal care for the patient if they wish to
do so
• Explain how to assess, tailor and document regular monitoring of patient’s:
o symptoms, comfort, hygiene, observations and ongoing interventions
3
Communicating with and respecting the dying
patient
What is the first thing you, as a health care professional, should do upon entering
a room or bed space of an unresponsive patient who is dying?
4
Communicating with and respecting the dying
patient
• Introduce self and role to patient and others in the room
• Sensitively communicate with the dying person, and those identified as
important to patient
• Talk as if the patient can hear you, even if he/she appears to be unconscious
or restless. The patient may also be aware of people around them
• Simple, respectful explanations of the care you will be providing remain
important elements of care
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Delivering sensitive, gentle personal care
Consider for a moment you are the dying patient in the bed
1.
What would be important to you at this time?
2.
If you could talk to the people who are caring for you, what would you tell
them?
3.
What would “good care” look like to you?
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Delivering sensitive, gentle personal care
For terminally ill patients, dissatisfaction with care is often
related to ‘the devaluing, dehumanising effect of inadequately
provided personal care’
(Rogers et al, 2000)
•
An unconscious patient at the end of life is wholly dependent on you to meet
their personal care needs
•
Care must be patient centred, individualised and take into account any
religious, spiritual and cultural beliefs, values and norms
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Delivering sensitive, gentle personal care:
continence care
• Goal of continence care is ensuring the patient is comfortable and dry, paying
attention to skin and pressure areas
• Poorly managed bowel and bladder care can cause several complex difficulties
for the patient
• An indwelling catheter and/or absorbent pads and/or convene/sheath may be
used
8
Delivering sensitive, gentle personal care: Skin
care and repositioning
• Patients at the end of life are at significant risk of skin damage and breakdown
• Skin care at this time has three main components: assessment, cleansing and
positioning
• The patient should only be repositioned to maintain comfort
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Delivering sensitive, gentle personal care: vital
signs and observations
• Ask: How likely is it that this investigation or treatment will help this patient at
this time?
• The multidisciplinary team must discuss, together with the patient and
persons important to them, the appropriateness of continuing vital sign
monitoring and observations, including blood tests
10
The importance of good oral care
• Why might a patient be at risk of poor oral hygiene at the end of life?
• What would you include in an oral hygiene care plan for a patient at the end of
life?
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The importance of good oral care
• A healthy mouth is clean, moist, and pain free. Oral care should focus on:
o patient's comfort
o be tailored to individual need
o be discontinued if causing distress
• 1-2 hourly mouth care is advised if a patient too unwell to undertake good oral
care
• Mouth care can be carried out by the family / those important to the patient
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Recommendations for oral hygiene care
• To clean teeth: use a small headed soft bristle toothbrush or foam sponge if a
toothbrush isn’t tolerated
• To clean the oral mucosa: use a moist foam swab
• If the patient becomes agitated or distressed, discontinue the procedure
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Support the people important to the patient to
provide personal care
• If the people important to the patient wish to be involved in the patient’s
physical care, what are the advantages of this:
o for the patient
o for family and persons important to the patient
o for health care professionals?
• Discuss how to involve and support persons important to the patient in the
patient’s care
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‘Most of the time I was by his bed, helping with the nursing and being allowed to
continue to care and support him as I have done for many years... Above all I was
with him at the end of his life.’
Family member
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Ask:
How can we work together to best look after [the name of the person being cared
for]?
• Actively explore, respect and meet where possible the needs of families and
others identified as important to the patient
• Persons important to the patient have their own needs which can be
overlooked at this time; including anxieties, fears, feeling distressed, emotional
and physically exhausted
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Regularly monitor symptoms and comfort,
providing individualised care
• Agree, co-ordinate and deliver with compassion an individual plan of care
• Assess at least every four hours in accordance with the patient’s wishes and
the wishes of those important to them
• Documenting individualised care will improve the quality of care provided
17
Activity
List non-verbal signs of discomfort and pain that a patient thought to be at the
end of life may demonstrate
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Physical care at the end of life
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