Rapid Discharge Guidance for Patients in last days or weeks of life (709)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

 

   A PDF version of this guideline is available for download

Follow steps below...

Follow steps below to facilitate seamless discharge from Hospital, where possible within working hours

Medical

Nursing

Symptom Control

  • Rationalise medications.
  • Prescribe anticipatory end of life medicines (see overleaf).
  • Complete IDL prescription as soon as possible (minimum 5 day supply). Contact Pharmacy, highlight urgency and obtain advice if needed.
  • Identify continued need for oxygen. If oxygen is required contact Respiratory or Palliative Medicine as soon as possible.

Communication

  • Address any concerns patient, relative or friend may have regarding symptom management and comfort. Discuss what may happen if staying at home becomes too difficult. Reassure that a further admission to either hospital or hospice can be explored. If hospice is the preferred place of care/ death this will be dependent on bed availability. If hospital re-admission is required/ desired the patient will need to go through Accident/ Emergency Department before being transferred to a ward.
  • Discuss with patient, relative or friend what may happen at home. It may help to provide the booklet “What Can Happen When Someone is Dying”.
  • Provide numbers for all relevant services in and out of hours.
  • If any help/support is required with discharge contact discharge team/hospital palliative care team.

Communication

  • Address any concerns patient, relative or friend may have regarding symptom management and comfort.
  • Discuss with patient, relative or friend what will happen if staying at home becomes too difficult. Reassure that a further admission to either hospital or hospice can be explored. If hospice is the preferred place of care/death this will be dependent on bed availability. If hospital re-admission is required/desired the patient will need to go through Accident/Emergency Department before being transferred to a ward.

It is essential to speak with the District Nurse

  • Provide nursing handover on patient’s clinical condition, estimated prognosis, symptom management plan, DNACPR status, potential for any palliative care emergencies, medication, recent ACP discussions, equipment requirements and 24 hour care needs of patient.
  • Discuss with DN if Marie Curie Fast Track or equivalent referral has been made. Discuss with DN need for Marie Curie Managed Care (Overnight Nursing Service).
  • Identify the relatives or friends who will be supporting the patient at home, and any support they may require.

It is essential to speak with the GP

  • Provide medical handover on patient’s clinical condition, estimated prognosis, symptom management plan, DNACPR status, potential for any palliative care emergencies, medication and recent ACP discussions.
  • Ask GP to update KIS and commence Community Kardex.

Transport

  • Request transport as soon as the potential date of discharge is known and explain that this is the last journey.
  • Identify any accessibility issues and who will be travelling in the ambulance with the patient. Ensure patient, relative or friend are aware transfer onto a chair to get into the house may be required.
  • Escalate any transport issues to Discharge Team/Ambulance Liaison (if available) or escalate to Senior Management Team if required.
  • Show ambulance crew DNACPR form and send original form home with other documentation. Retain a photocopy, date and mark 2 lines across to identify this as a copy.

DNACPR

  • Ensure DNACPR form has been discussed with patient, relative or friend.
  • Complete DNACPR form including instruction for ambulance crew on the back of the form. Send original form home with the patient.
  • If the decision has been made not to send the form home with the patient the reason for this must be documented and communicated to GP/DN to allow them to record on KIS.
  • Further information including DNACPR Policy

Symptom Control - Immediately Prior to Discharge

  • Consider subcutaneous bolus of any of the anticipatory medication for the journey if needed. If patient is on a Continuous Subcutaneous Infusion (CSCI):
  • Refill the syringe pump as near to discharge time as possible.
  • Record the site of the Saf- T- Intima/line change on part 2 NHSGGC Discharge Letter/Transfer Plan.
  • Send the original, fully completed pink CSCI chart home with patient. Retain a photocopy.
  • Send home a jiffy envelope identifying where the pump has to be returned to. Ensure there is a ward/T34 pump hub record of serial number and pump destination.

 

Reminder: Review patient's condition  regularly and if deterioration is rapid consider discussing with patient, relative or friend remaining on the ward for the patient's last hours. Contact GP/DN if this occurs to cancel planned discharge. Click here for more detailed Guidance at the End of Life for Health Care Professionals

 

Abbreviations: ACP - Anticipatory Care Plan KIS - Key Information Summary
  CSCI - Continuous Subcutaneous Infusion JIC - Just In Case

 

Guidance for Regular and Anticipatory/Just in Case (JIC) medication

If unsure how to write prescription, (examples below) contact pharmacy early for advice and agree quantities
If additional information required, click on the links below.

Anticipatory Prescribing (Scottish Palliative Care Guidelines)
Guidance on how to write a controlled drug prescription (Acute Therapeutics Handbook)
Renal Disease in the Last Few Days of Life (Scottish Palliative Care Guidelines)

 

Follow this link to access the Regular and Anticipatory/Just in Case (JIC) medication pathway

 

 

Last reviewed: 17 December 2019

Next review: 31 October 2021

Author(s): Claire O'Neill

Version: 1

Author Email(s): claire.o'[email protected]

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 709