What is the Care Pathway for the Last Days of Life?
The care pathway is a tool which:
Section 1: Patient Assessment

Influences the type of care a patient is given
The assessment has specific goals 1-10:

Is a plan for health and social care professionals of how to provide multidisciplinary, evidence-based best practice whatever the diagnosis or location.
Goals 1-3 Comfort Measures / Clinical interventions

Provides guidance on the different care packages required, including: comfort
measures, anticipatory prescribing of medicines and discontinuation of
interventions which are no longer suitable,
Following assessment, decisions are taken on the patient’s condition. Inappropriate
interventions and non-essential medication may be stopped and the best route of
medication administration is identified. Preventive prescribing of “as required”
medication is completed to ensure any symptoms are managed without delay.
Note: It is perfectly acceptable, as a professional, to consider suitable alternative care.
However, you should record any changes on the Variance Sheet and explain the
change from the care pathway.
Goals 4 –10 Communication
Important: The care pathway forms part of the legal record of care and replaces
most other documentation.
Communication
The front page details the criteria for commencing the pathway and gives
instructions on how to sign goals and record variances. The signature log is a useful
reference, when following up an event and is mandatory. You only need to record this
once, not every shift.
The care pathway guidance has three sections:
1. Patient assessment made on diagnosing dying
2. Focus of patient care
3. Care after death.
Diagnosing Dying
A multidisciplinary team (MDT) approach to the diagnosis of dying is important. It
avoids giving conflicting messages to family / carers
All reversible causes for the current condition should be considered before the team
agrees that the patient is dying. The following may apply: The patient is:
Identify the patient/family/carer knowledge and their communication needs to find out
their understanding of the situation.
Family members need to be informed and consulted, but they should not be asked to
make decisions about the patient’s care. Decisions should be made by the patient if
they have capacity or a valid Advance Decision (ADRT). If not, after careful
consideration of the patient’s best interests, the team caring for the patient will make the
decisions (See: Mental Capacity Act policy).
Religion or belief is often recorded on
admission, but it is important that the
religious/spiritual needs of both patient and carer are reviewed. A review will avoid
assumptions of belief, wishes or desires of patient care.
Contact details that were recorded on
updated information must be recorded.
admission need to be checked and any
Note: Remember that primary contact and next of kin may be different people.
It is important that: family and carers are aware that the care pathway has begun; their
concerns are identified and documented; they have understood the plan of care.
There are specific information booklets regarding the Care Pathway available for
Relative/carers “When someone is dying”
1. Essentially bed bound
Communication with Primary & Secondary Healthcare Teams
2. Increasingly drowsy
3. Finding it difficult to swallow
It is important to keep other teams updated as they may be unaware of the situation
and care pathway.
At this stage, to avoid unnecessary and futile actions, end of life care decisions will
require completion, including:
Section 2: Focus of Patient Care

Do Not Attempt Resuscitation (DNAR).

(EMAS) end of life care decisions.
It may also be relevant to complete a “Nurse Verification of Expected Adult Death”.
The GP or hospital doctor will sign the pathway following the MDT agreement.
Assessments are also made that relate to:
Pain and Comfort Measures
*Pain *Agitation
*Other symptoms.
*Nausea and vomiting *Respiratory Tract Secretions *Dyspnoea
Essential Care
*Mouth care
care
*Micturition
*Medication
*Immobility *Personal hygiene *Bowel
These are specific goals (1 - 3), which should be assessed regularly. The frequency
depends on the location of the patient.
In an inpatient unit or care home, assessments will be at a least every 4 hours. In the
community setting it will be made at the time that a health or social care member visits
the patient. These assessments will help maintain up to date information and the need
for continued use of the care pathway.
Multidisciplinary Progress Notes
The Multidisciplinary Progress Sheet can be used to record any significant
event/conversation that has not already been recorded on the care pathway, e.g:
* A specific conversation with a named carer
* Information following a ward round / visit.
Variance Reporting
If the care pathway is not followed at any point, the reason must be recorded as a
variance on the Variance Sheet.
Care Pathway for
The Last Days of
Life
Variance is an important part of the care pathway, it should not be seen as a negative
process.
Section 3: Care after Death
This section is intended to guide the multi-disciplinary team to support the family/carers
after death. This can be a distressing time and so it is important to ensure they have
been given the necessary documentation.
It is important to ensure that the information required to allow someone to collect a
Death Certificate and belongings is understood in advance to avoid unnecessary
distress.
It is hoped the use of this care pathway will help all those involved in achieving and
maintaining a high standard of care of the dying.
Symptom management guidance is attached to the Pathway.
For further advice or if problems persist the
Specialist Palliative Care Team should be contacted.
With acknowledgement to Marie Curie Palliative Care Institute
Are we accessible to you? This publication is available on request in other formats (for
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and/ or format please call 01773 525099 extension 5587, or e-mail at
Communications@dchs.nhs.uk
Promoting Best Practice in the
Care of Dying Patients
Staff Guidance