Nice | End of Life care

This is a new guideline from NICE on end of life care. You may have heard it widely reported in the news, given all the attention over the Liverpool Care Pathway. What was reported as being different was the focus on communication with the patient and delivering an 'individualised' approach. This is really the biggest part of this guideline. There wasn't much different in terms of medications advised, or other management.

If you want a bit of a revision of symptom management, then I would strongly advise a read of the guideline, but skip down to 1.4...

I'll summarise things I felt were different or that I wasn't fully aware of.

In our area, the 'little green book' of palliative care can be accessed online (though the last update is from 2010 as far as I'm aware). Quite a handy one to have on your phone...

 General approach

Always consider that the patient may temporarily improve. This may alter how you manage the patient.

Communicate with the patient every step of the way. In particular discuss:

  • whether they want someone else involved in discussions over their care.
  • their wishes, goals and preferences.
  • their prognosis and understanding of the situation (if they want to know).
  • any fears and anxieties they may have.
  • any advance statements, powers of attorney etc that they may have.

Only do tests if there is a clinical need.

Review the patient every 24 hrs (the guideline is talking about the last 2 - 3 days of life).

Clinically assisted hydration

This was obviously highly politically charged in the Liverpool Care Pathway, so discussion of pros and cons is important. A trial can always be started. Once started, patients should be monitored every 12 hrs. Explain that:

  • hydration may relieve symptoms (eg thirst, delirium), but may cause other problems (eg fluid overload).
  • it is uncertain whether providing clinically assisted hydration could extend the dying process or prolong life.
  • it is uncertain whether not providing clinically assisted hydration could hasten death.

Pain

Not everyone dying is in pain (I know this sounds obvious, but sometimes it kind of gets a bit lost among everything going on).

Consider any reversible causes (eg urinary retention, a full rectum).

Noisy respiratory secretions

Reassure and explain that although it isn't very nice to listen to, it normally doesn't cause any discomfort to the patient.

Only treat if it is distressing to the patient.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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