Subcutaneous administration of anticipatory medicines via a Saft-T Intima is best practice in EoLC due to minimized discomfort, fast absorption and lack of other viable routes. Anticipatories can be given as boluses or, ideally, as a continuous infusion via a syringe driver.
Saft-T Intima
A fine bore cannula inserted into the subcutaneous tissue of the upper arm, front thigh or lower abdomen and covered with a clear film dressing. Site changes at 7 days or sooner if signs of infection, inflammation or swelling are observed.
Flush the cannula with 0.2ml of 0.9% NaCL before and after administering medications if giving boluses. No more than 2ml of fluid should be administered at one time, with at least 1 hour between doses.
Located in the majors store, cupboard 3 drawer 6.
Syringe Driver
In ED, we have one BD Bodyguard T Syringe Driver.
Medications via a syringe driver require a separate prescription to bolus doses and you must have Trust competence to use one. If you need a refresher, a user guide can be found on the Intranet under the ‘End of Life’ tab.
If you do not have the competence, find someone who does!
On occasion, bolus doses are suitable in patients in their last hours of life, particularly if they appear symptom-free. In all other cases, advocate for a syringe driver prescription with the doctor in charge of care.
Located in the majors clean utility, key in cupboard behind reception.
Anticipatory Medications in ED
- Morphine – pain and shortness of breath
- Oxycodone – pain and shortness of breath
- Haloperidol – nausea and vomiting, confusion, agitation
- Hyoscine Butylbromide (Buscopan) – noisy, wet breathing and spasmodic pain
- Midazolam – shortness of breath, anxiety, agitation, sedation
In patients experiencing myoclonic seizures, most apparent after extubation, opt for midazolam rather than haloperidol.
Note for nurses: there will always be a ‘last’ injection before death, the administration of anticipatories is not the cause of death, it is not your fault the patient has died. You have helped their last moments be comfortable and pain-free.
After the verification of death, there is a 4 hour time period in which relatives can be with their loved one and for Care After Death to be performed.
Care After Death checklists are located in the store cupboard adjacent to cubicle 9, in the resus paperwork folder and on the intranet. Death certificate books are located with the resus paperwork and must be completed by the doctor at the time of verification.
Nursing care should not change during care after death, continue being gentle, careful and talk to your patient. Adhere to their wishes as best you can.
All belongings, if not taken home by relatives, must be bagged, labelled and sent to the General Office as soon as possible. Record any jewellery in situ on the death certificate.
Transfer patient to the bereavement room in resus.
Timely transfer to the mortuary (Rose Cottage) is important, be transparent with relatives about this so they can prepare for leaving their loved one.
Transferring a patient undergoing EoLC to the ward can be a worrisome experience. It is unlikely, though not impossible, that the patient will die during transfer.
To make this easier:
- Communicate with relatives, allow them to travel with the patient if they would like
- Communicate with porters so they can ‘key-off’ lifts to prevent delays
- Continue talking with you patient, explain where they are going and who is going with them
Should a patient die during transfer, continue to your destination and handover to the new named nurse. This ensures any relatives have some final time with their loved one, a clinician can verify death and the patient can receive care after death.
