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Postprocedure

40 A follow-up phone call should be made to establish how the patient is managing. To ensure services are in place. E

Box 2.15 Patients with particular care needs on discharge

Live alone.

Are frail and/or elderly.

Have care needs which place a high demand on carers.

Have a limited prognosis.

Have serious illnesses and will be returning to hospital for further treatments.

Have continuing disability.

Have learning difficulties.

Have mental illness or dementia.

Have dependants.

Have limited financial resources.

Are homeless or live in poor housing.

Do not have English as their first language.

Have been in hospital for an ‘extended stay’.

Require aids/equipment at home.

(DH 1989, 2004a)

Postprocedural considerations

Discharge delays

A discharge delay is when a patient remains in hospital beyond the date agreed by the multidisciplinary team and beyond the time when they are medically fit to leave (DH 2003a). For every patient who is ‘delayed’, the trust is required to inform the Strategic Health Authority through the SITREP reporting mechanism which is normally captured at a point in time each week. It is the responsibility of health authorities, in collaboration with Social Services departments, to monitor the way in which discharges from hospitals are being undertaken and, if problems occur, to establish the reasons, so that any necessary changes are made to address the local needs (DH 1989). Each hospital should have at least a basic system of audit and quality control of discharge practice and procedures.

Care of the dying patient

Definitions

Terminal illness

Describes any disease which is at an advanced stage or has no known cure.

Palliative care

The term used for care, wherever and by whomever provided, which seeks to improve quality of life through the prevention and relief of suffering in the time leading up to death (Higgins 2010). Palliative care is applicable from early in the course of an illness, in conjunction with other therapies which aim to prolong life (WHO 2002; www.who.int/cancer/palliative/en).

Terminal phase

‘The ill-defined period of irreversible decline that heralds imminent death. This is usually a period of several days, but may be as short as a few hours, or as long as a couple of weeks’ (Back 1992). The expression ‘terminal care’ applies to care given during this period of time.

Anatomy and physiology

In the days and hours leading up to an expected death, the following are common.

A weaker pulse (but regular unless previously arrhythmic).

A gradual drop in blood pressure (though at this stage it should not be routinely taken).

Shallower, slower breathing which varies in depth, often in a Cheyne–Stokes pattern.

A decreasing level of consciousness leading eventually to coma, except in those few patients who remain awake until a few minutes before they die.

Cooling and clamminess of the skin from the periphery inwards.

Cyanosis of the skin on the extremities and around the mouth.

Eventual loss of all signs of cardiorespiratory function and the corneal reflex – death is said to occur at this point (Fürst 2004).

Related theory

Care of the person who has reached the final stage of their life is a key aspect of maintaining human dignity and is enormously important for relatives and friends who will remember this period perhaps better than any other during the cancer journey. Unrelieved suffering of patients at the end of life is associated with increased relative distress and can unnecessarily complicate the already difficult period of bereavement. Nursing care during this period does not simply represent a continuation of previously given care, nor necessarily the complete cessation of all ‘active treatment’ measures which may previously have been undertaken. As with all aspects of nursing care, assessment of the individual patient and their relatives, exceptional communication and good multiprofessional working will help to determine the appropriate next steps for each