16.14 Care in the last few days of life

Please refer to local guidelines for the care of dying patients for more information about caring for those in the last few days of life.

It is important to recognise when a patient is dying so that care can be prioritised.

Advance Care Planning (ACP) can help the patients and those close to them prepare for the future. It gives an opportunity to think about, talk about and write down preferences and priorities for future care, including how they want to receive care towards the end of life.

The Advanced Care Planning booklet can be downloaded from the NHS Devon CCG website, along with resources for healthcare workers around treatment escalation plans (TEP).

Priorities:

  • Rationalising regular medication: stop all drugs and interventions which are not contributing to immediate comfort
  • As patients become unable to take medications by mouth, convert essential medications to the subcutaneous route (especially those for symptom control)
  • Prescribe when required "Just in Case" medication for pain, breathlessness, agitation or chest secretions
  • Review hydration – consider carefully benefits/burdens of continuing/starting artificial hydration. It is not precluded in the dying patient. However a careful discussion of the potential burdens of artificial hydration and the benefits of good mouth care may be what is needed
  • Communication and acknowledgement of life coming to an end with support to patient and family
  • Spiritual and psychological issues
  • Contact with family and friends

Drugs to consider discontinuing in advanced disease

Discussion with patients before discontinuing a medication is very important.

Because of likely harm

  • Examples include metformin in patients with diminished appetite and at risk of liver and renal failure
  • Anticoagulants when advancing disease makes them more susceptible to bleeding and clotting
  • Anti-hypertensives as hypotension becomes more common in advancing disease

To reduce tablet burden

  • Drugs which often become unnecessary in advancing disease include statins and long term treatments for osteoporosis.

 

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