Care of Dying Adults in the Last Days of Life
National Clinical Guideline Centre. (2015).
London (United Kingdom): National Institute for Health and Care Excellence, (NICE Guideline 31), 1-270.
This guideline from the National Institute for Health and Care Excellence provides recommendations regarding palliative care for adults. The following summary highlights recommendations within the scope of speech-language pathology.
National Institute for Health and Care Excellence (United Kingdom)
<div>If it is likely a person may be entering their final days of life, providers should assess and gather and document information about the person's:</div>
<div>
<ul>
<li>physiological, psychological, social, and spiritual needs;</li>
<li>current clinical signs and symptoms;</li>
<li>medical history and clinical context of disease;</li>
<li>goals and wishes; and </li>
<li>views of the patient and those important to the patient regarding future care. </li>
</ul>
</div>
<div>If a patient is approaching their final days of life, providers should avoid undertaking assessments that are unlikely to affect care unless there is a clinical need to do so. Patients should be monitored for further changes in status every 24 hours to determine if they are nearing death, deteriorating, stabilizing, or improving, with appropriate updates to plan of care as needed. </div>
<div>Clinicians should establish dying patients' desired degree of involvement for shared decision-making. Clinicians should be honest and transparent during any discussions about plan of care development and implementation. As part of the shared decision-making process, clinicians should:</div>
<div>
<ul>
<li>take into account the patient's goals and whished, whether or not the patients has any advanced directives, a legal lasting power of attorney for medical and welfare decisions, and any cultural, religious, spiritual, or social preferences;</li>
<li>ensure that any agreed changes to plan of care are understood by the dying person, those important to them, and anyone involved in their care;</li>
<li>establish an individualized plan as part of a multidisciplinary team, care taking into account personal goals/wishes, preferred care setting, current and anticipated care needs, preferences for symptom management, and needed resources;</li>
<li>clearly document plan of care discussions and decisions and share this plan with the dying person, those important to them, and all members of the interdisciplinary team;</li>
<li>continuously re-evaluate the patient's and their care partner's understanding and wishes, with adjustments to the plan as needed;</li>
<li>recognize that a patient's desire to be involved in shared decision-making may change over time as their condition deteriorates or the patient begins to accept their prognosis;</li>
<li>meet the wishes of the dying person if at all possible, explaining rationale behind any situation in wishes are not able to be honored; and</li>
<li>ensure that shared decision-making can be supported by experiences staff at all times, with referral for specialist advice if additional support is needed. </li>
</ul>
</div>
<div>Providers should assess and document the communication needs and expectations of patients who may be entering their last days of life, taking into account:</div>
<div>
<ul>
<li>if they would like a person important to them present when making plan of care decisions;</li>
<li>their currently level of understanding of prognosis and that they are nearing death;</li>
<li>their cognitive status and if they have any specific speech, language or other communication needs;</li>
<li>the degree that they would like to be informed about their prognosis; and</li>
<li>any cultural, religious, social or spiritual needs or preferences.</li>
</ul>
</div>
<div>Dying patients should be supported to drink if they wish to and are able to. Clinicians should:</div>
<div>
<ul>
<li>assess for any difficulty swallowing and aspiration risk;</li>
<li>discuss the risks and benefits of continuing to drink with the dying person and those involved in their care;</li>
<li>offer frequent oral care and include dry mouth management interventions, if needed;</li>
<li>offer assistance with cleaning the dying person's teeth or dentures and offer frequent sips of fluid;</li>
<li>encourage people involved in the dying person's care to help provide oral care and sips of fluid with appropriate education and training;</li>
<li>educate the dying person and their family about the potential risks and benefits of assisted hydration (e.g., relief of distressing symptoms, fluid overload) and the clinical uncertainty of whether alternative hydration may prolong life, extend the dying process, or hasten death;</li>
<li>assess, preferably daily, the dying person’s hydration status, and review the possible need for starting clinically assisted hydration, respecting the person’s wishes and preferences; and</li>
<li>use an individualized approach when considering the recommendation of assisted hydration, taking into account any advanced directives, any cultural, spiritual, or religious beliefs that may influence decision-making, the patient's level of consciousness, the presence of any swallowing difficulties, their level of thirst, adequacy of oral hydration, risk of pulmonary edema, and whether any temporary recovery is possible.</li>
</ul>
</div>
<div>When making recommendations regarding the most effective route of medication administration, clinicians should consider the dying patient's ability to swallow , their overall condition, their preferences, and their tolerance of oral medications.</div>
