Last Updated on May 5, 2016
New guidelines set out how to give people the best possible care at the end of their lives. The new guidance from the National Institute for Health and Care Excellence (NICE) aims to support healthcare professionals in giving consistent, compassionate and high quality clinical care to people in their last days of life.
It’s estimated that about half a million people die each year in England and three out of four of these deaths are expected. A recent report, by the Economist Intelligence Unit, ranked the UK as having the best end of life care in the world, but also outlined areas where improvements still need to be made.
Professor Gillian Leng, Deputy Chief Executive of NICE, said, ‘Death is something that happens to us all and how we are cared for can make a big difference to our final days.
‘We know the vast majority of people in this country receive very good end of life care, but this isn’t always the case. Looking after people who are dying can be challenging and our new evidence-based guideline will support doctors, nurses and other healthcare professionals to provide the best care possible for every patient.’
The NICE guideline follows the abolition of the Liverpool Care Pathway, a protocol for looking after people at the end of their life. This was phased out in 2014 after a Government-commissioned review found serious failings in how the pathway was being implemented and recommended it be replaced with individualised care plans for dying people.
The NICE guideline is aimed at supporting healthcare professionals in all areas of the NHS, including GPs, nurses and hospice workers.
Identifying when a person is entering the last few days of their life can be difficult; how long it takes and the ways in which people die can vary and depends on a person’s condition. The NICE guideline will help doctors, nurses and other healthcare professionals to recognise when a person may be entering the last days of their life, or if they may be deteriorating, stabilising or improving. It sets out what information should be recorded and signs to look out for which may indicate if the person is recovering or deteriorating.
It also recommends that:
- Tests which are unlikely to affect care in the last few days of life should be avoided unless there is a clear clinical need for them.
- Advice should be sought from colleagues with more experience of providing end of life care when there is a high level of uncertainty about whether a person is entering the last days of life, or if they are stabilising or recovering.
Poor implementation of the Liverpool Care Pathway often led to dying people becoming dehydrated. The NICE guideline supports the use of offering fluids when it is the person’s wish or if they may help medically. It recommends that people who are in their last days of life should be supported to drink if they wish to and are able to. Healthcare professionals should assess the dying person’s hydration status daily to review if they require fluids given through a drip (clinically-assisted hydration).
If it is thought that a person would benefit from having fluids through a drip, the guideline advocates that risks and benefits should be discussed with the dying person and those important to them. They should be advised that whilst giving fluids in this way may relieve some problems, they could cause others and that, in a person already near death, there is medical uncertainty whether giving assisted hydration prolongs or shortens a person’s life.
A report by the Parliamentary and Health Service Ombudsman earlier this year outlined concerns over end of life care such as a lack of communication and poor symptom control. The NICE guideline supports clear communication between healthcare professionals, the person who is dying and those important to them. It emphasises the need for shared decision-making between all concerned. Its recommendations include developing individualised care plans in discussion with the person who is dying, their families and others important to them, and which clearly take into account the dying person’s needs and wishes.
The guideline also sets out a series of recommendations to manage symptoms that may develop at the end of life. These include nausea and vomiting; pain; breathlessness; noisy respiratory secretions; and anxiety, agitation and delirium.
It also recommends that doctors review a person’s medication once it is recognised that they may be entering their final days of life. Any previously prescribed medicines that are not helping to alleviate symptoms or that may cause harm should be stopped following a discussion and agreement from the dying person and those important to them. Drugs prescribed in anticipation of a person dying should be based on their likely future symptoms, and not in a blanket fashion.
The Guideline Care of dying adults in the last days of life is available on the NICE website here.