• Increased weakness/fatigue – sleeping more, drowsiness, reduced activity and mobility
• Loss of appetite and thirst – not wanting to eat/drink, dysphagia
• Breathing changes – shallow, irregular or agonal breathing
• Skin changes –  pale, mottled, cool and clammy skin
• Reduced output – significantly reduced or total absence of bladder/bowel output
• Communication changes – reduced responsiveness, difficulty speaking, declined cognitive function
• Behavioural changes – restlessness, agitation, confusion, reaching out into the air
• Deterioration – ongoing deterioration despite aggressive active treatment of usually reversible causes in acutely unwell patients

• Transfer patients onto a hospital bed, preferably with an air mattress for comfort and skin integrity
• Remove all observation monitoring including defib pads
• Removal of IVA and airway adjuncts with doctors permission
• 2 hourly mouth-care and repositioning, using a sponge and mouth-care gel or water if gels are unavailable
• Regular continence care to maintain dignity and skin integrity
• Utilise the cubicle computers/radio to play music or TV the person likes
• Ensure anticipatory medications are prescribed and administered appropriately
• Read Advanced Care Plans, adhere to the person’s wishes as best you can
• Talk to your patient, they may not respond but they can still hear you
• Ensure a quiet, peaceful environment – this is not always easy in ED but turning monitors on ‘standby’ in surrounding cubicles can make a small but not insignificant difference
• No one should die alone, make efforts to stay with the patient – this can be tricky in a pressured ED, BLOSM are often happy to help spend time with patients in their last hours if their caseload allows
• Be the attentive, caring nurse you already are

• Please ensure Anticipatory Drugs are preceded for patients – there are 2 versions (1 for renal impaired patient and alternative for those without renal impairment)
• Breathlessness – cool air moving over the face
• Respiratory Secretions – repositioning, gentle suction, reassure relatives that secretions do not usually cause distress to the patient
• Pain – timely position changes, warm/cool therapy, dressing wounds and splinting fractures
• Agitation – nurse in a calm, quiet environment, provide comfort items, play music, ensure continence needs (catheters may be appropriate for urinary retention at end of life)
• Dryness – regular mouthcare, skin cream, and ‘tastes’ of juice/tea on a sponge

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.

At the end of life, open and honest communication helps the patient and their relatives understand the situation and set realistic expectations. The possibility of death should be recognised and communicated early on, with actions taken promptly and documented clearly.

Breaking bad news should be done in pairs and led by the doctor in charge of care, making use of the relatives room where possible.

Patients and their relatives may have lots of questions, allow them time to comprehend what you are telling them, provide a pen and paper for questions they may have and return when they have had time to process.

In some circumstances, telephone may be the only form of viable communication with relatives. Maintain the same open communication, ensure they are in a suitable setting and give a ‘warning shot’ i.e. “I am calling to let you know X’s situation has changed…”

We are often asked, “How long do they have left?”, this is a question we cannot answer definitively, so ranges of ‘hours to days’ or ‘days to weeks’ are our closest way of communicating dying to relatives.

Conversations about death do not have to always be ‘bad news’, they allow for exploration of what a good death might look like for the person you are caring for and their families.

Ask questions like:

• What can I do to help you feel more safe/comfortable?
• Is there anyone you would like me to contact or ask to come in?
• If your wife could talk to me, what would she tell me she wanted?
• Has your dad expressed any wants for how/where he would like to be cared for?
• Is there anything you are fearful of or worried about?
• Would you like a chaplain to visit?

A patient’s preferred place of death should always be considered in their management plan. These places may include:

• At home with GP and district/hospice nurse support
• In hospital with use of the Marigold Scheme
• A care home (new or returning resident)
• A hospice (Kirkwood for Kirklees residents, Overgate for Calderdale residents)

Support for discharging patients at the end of life is led by CHFT’s Palliative Care Team, they are able to make fast-track referrals to help adhere to our patients wishes. Referrals to hospices can also be made by a hospital consultant or the patient’s GP.

Unfortunately, we cannot always adhere to our patient’s preferred place of death. Hospices are under the same bed pressures as hospitals and have strict admission criteria. Similarly, a patient may be unable to transfer home or to a ward – maintain transparent communication with the patient and their relatives about this.

Marigold Scheme – located in bereavement room cupboard

• Identifiable marigold flower magnets for the cubicles of patients receiving EoLC
• EoLC care kits including mouthcare supplies, creams and socks
• Free parking for visiting relatives
• Information packs for managing funerals, admin and wellbeing
• Allowing relatives to ‘feel useful’ by involving them in simple tasks like mouthcare and repositioning if they would like, but never expect them to do so

Kirkwood Hospice Bereavement Support

The following can be accessed via 01484 557910

• Pre-bereavement counselling, psychotherapy and education
• Post bereavement 1:1 counselling, psychotherapy and family support
• Telephone helpline service
• Bereavement support group, fortnightly on a Tuesday from 10am – 12pm
• Newly bereaved (2-12 months) support group fortnightly on a Tuesday 10am – 11am

• Kirkwood Hospice 24/7 Helpline: 01484 557910
  • Advice around uncontrolled pain, supporting relatives and supporting professionals
• SHOUT
  • Text ‘SHOUT’ to 85258 for textline emotional support
• Samaritans
  • Call 116 123 for phoneline support
• WY HUB
  • Visit co.uk for healthcare-specific wellbeing support
• Each other – one of our greatest strengths in ED is our support for each other. Talk to your peers, your seniors, ask for that debrief. It’s highly likely someone is feeling or has felt the same way you are. Whether it’s your first death or your 50th, traumatic or peaceful, you chose healthcare because you care, so patient death will never be easy.