6 Steps to Success in End
of Life Care in residential
homes
workshop 4
Pam Williams
Clinical Nurse Educator
End of Life Care
May 2011
Objectives of the day
Delivering high quality end of life care;
 Define
‘high quality end of life care’
 Identify a training matrix template for all
staff in EOLC,
 Recognise the importance of Significant
Event Analysis
What is high quality end of life care
 Comfort
 Support
 Environment
 Planning
 Expertise
COMFORT
 Your
experiences
 What provides comfort?
 What
are the barriers to providing comfort
for palliative & dying residents in your
home?
 How can you overcome them?
SUPPORT
 For
staff
 For
residents
 For
families/friends
 Who
and how?
ENVIRONMENT
 Your
 What
experiences
are the barriers to providing the right
environment for palliative & dying
residents & their families in your home?
What does the end of life care
strategy say?
 Rooms
where residents and families can
talk privately
 Rooms
where family can stay overnight
with facilities for catering and
communication
What should we consider?
 First
impressions- professional but
reassuring
 Nature – natural materials and elements
 Beauty & arts and crafts
 Dignity & privacy
 Comfort
 Robustness
 economy
And….
 Free
of clutter
 Good natural light and fresh air
 Information
 Conducive
 Is your notice board appropriate
 Hire a skip and have a decluttering day
Ask yourself…
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Can residents exercise control over their
environment?
Can they adjust their bed?
Do they have access to tv/radio/music?
Have unwelcome sounds/smells been
minimised?
Can windows be opened?
Can residents see the natural world from their
bed?
Are chairs provided for visitors?
What can you do?

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Create a peaceful environment
Give residents/families as much control over the
environment as possible
Maximise views of gardens etc
Suitable lighting
Ensure access to music/tv
Ensure chairs are comfy for people staying for
long periods of time
Make sure the room is clean, tidy and pleasant
Ask residents & relatives what they want!
Planning & evaluating plans
 Learning
 Sharing
your learning with colleagues
 Reflecting
 Using
on plans
learning to improve planning
Training plans

Think about the different groups of staff in your
home

How would you devise a training plan to meet all
their needs
What topics would you include
Who would deliver the training
When & how would that happen
Consider as many types of training as you can

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EXPERTISE
 How
can all care home staff access
relevant end of life care training?
 Internal
 External
What can I do next?
 Distance
learning
 Elearning
– skills for care/skills for health
 Diploma-
(NVQ)
 Degree
– Care of the Dying module
Significant event analysis (SEA)
 The
importance of reflection
Other ways of reflecting
 Supervision
 Post
death audit tool
 Lessons learned sessions
Simple ways to maintain comfort
 Therapeutic
 Good
touch
mouth care
Hospice therapy team
The benefits of therapeutic touch.
THE IMPORTANCE OF GOOD
MOUTH CARE
WHY IS GOOD MOUTH
CARE IMPORTANT
FOR OUR
RESIDENTS?
HOW DOES GOOD MOUTH CARE
IMPROVE QUALITY OF LIFE?

The structures of the face including lips &
cheeks contribute to communication
 The tongue, palate & teeth serve a large number
of functions including defence against infection,
incision, chewing, signalling with facial
expression & speech,
 Gestures for contact & grooming for love &
affection
 Quality of life depends on keeping these
functions intact as long as possible
THE PATIENTS POINT OF VIEW
 Ability
to communicate easily
 To
taste & enjoy food & drinks
 To
be nice to be near
 Dignity
& self-respect
SIGNS & SYMPTOMS

Poor oral hygiene can contribute to poor appetite, leading to weight
loss and malnutrition, and has also been associated with the
development of aspiration pneumonia in the elderly. This can lead to
the resident being identified as end of life prematurely.

Symptoms of Poor Oral Hygiene
Dirty mouth
Furred tongue
Sore, painful mouth
Bad Breath
Dry mouth
Oral Candidiasis
Viral Ulcers
Excessive salivation
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ORAL CARE IN THE ELDERLY
DEPENDANT PERSON

As a person ages, the soft tissue around the teeth
becomes harder making it harder for the individual to
detect painful toothache.
 Older people are more prone to problems with the gums,
salivary glands, lips, muscles and jaw bones.
 Also the amount of saliva and person produces, which
helps to clean teeth, decreases with age, leaving the
mouth more vulnerable to tooth decay and infection.
 Maintaining oral hygiene is very difficult for dependent
elderly who cannot brush their teeth.

They rely on you to do this for them!
One of these patients has dementia
and one has paralysis from a
stroke
Both of these patients were unable to maintain their own oral hygiene
and has clearly been neglected by the people who should be
helping them.
Oral care in the final days

People in the last 24-48 hours of life often have difficulty taking fluid,
food or oral medication (Ellershaw et al, 1995)

Symptoms of dry mouth & thirst are common in dying patients
whether they are dehydrated or not. Reversing dehydration has little
effect on symptoms for the majority of people (Ellershaw et al, 1995)

Simple measures can be used as often as needed to maintain a
moist mouth

Frequent mouth care is used as often as necessary to maintain a
clean & moist mouth. This can often be done by the family, giving
them greater involvement caring for their relative

Mouth wash containing alcohol is very drying to the mucosa
End of Life
 Dying,
semi/unconscious patients are
unable to contribute to their own oral care
 They are also unable to swallow their own
salivary secretions
 Excessive secretions can be treated with
medication
 Oral hygiene is a vital part of end of life
care- DIGNITY, RESPECT, COMFORT
How do we maintain good oral care in dying
patients?

The prescribing of any oral care preparations
you need are as vital as end of life drugsremember to ask the GP to prescribe these too!
 Use a soft, baby toothbrush & clean gently
around the teeth, gums & tongue.
 Use a small amount of water or appropriate
mouthwash on the toothbrush as you will be
unable to rinse toothpaste out of the mouth.
(unless you have access to suction & a Yanker
suction catheter)
 Then apply any product/treatment currently in
use i.e. nystatin
Lips
Finish off by
 wiping gently around the mouth
 Applying a moisturiser to the lips i.e. vaseline, to prevent
dryness & cracking.
 Document the care delivered, recording date, time &
signature
 If you feel confident to do so, you can teach family
members to do this if they wish.
 Be sure to document this too and that they have
expressed a wish to do this. Ask that they let staff know
each time they have delivered oral care, for
documentation purposes.
And finally…
 Myth
1 teeth are just for looks
 Myth
2 its only a dry mouth- no big deal!
 Myth
3 resistance- its not worth it
 Myth
4 soaking dentures overnight is
enough
Dignity
A
parting thought!
 What
do you see nurses?
Small change - big difference

Clean clothes & bedding & tidy room
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Good personal hygiene
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Respect for privacy

Can everyone see packs of incontinence pads
when visiting?
 Can everyone see photographs of pressure
sores when looking in notes?
The policy

There is a process in place to identify the
training needs of staff and staff will have access
to end of life care training, particularly those
involved in discussing end of life issues with
residents & families.
 There is a process in place to reflect on end of
life care and utilise lessons learned to provide
continuous improvement.
 The environment within the care home offers
privacy, dignity and respect for individuals and
their families as end of life approaches.
Objectives achieved?
 Define
‘high quality end of life care’
 Identify
a training matrix template for all
staff in EOLC,
 Recognise
the importance of Significant
Event Analysis
To do list
Feedback to all staff contents of Step 4 workshop
Complete an end of life care training needs analysis for all staff
Review available options for accessing end of life care training locally
and implement a training plan
Commence the implementation of a Dignity Champion if not already
identified within the home
Review the environment and implement any necessary achievable
changes.
Bring to the next workshop any literature used within the home to
support residents, relatives and significant others when residents are
at the end of life
Continue to complete the post death audit form
Any questions?