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Assessment of religious/spiritual needs

Assessment of communication needs

Ongoing assessment Four-hourly nursing assessment of symptom control Pain

Agitation

Respiratory tract secretions

Nausea and emesis

Other symptoms such as dyspnoea

Oral hygiene

Elimination needs

Safe delivery of medication

Mobility/pressure area care

Psychological support

Religious/spiritual support

Needs of family/significant other

Care after death Discussion with family

Correct documentation

Last Offices

Property/valuables

Family information

Bereavement booklet

Informing GP/appropriate organizations

Reproduced from Jevon (2010).

The LCP is a useful tool in prompting the multiprofessional team to consider different aspects of caring for the dying patient and their relatives. It makes provision for regular assessment of the patient and relatives, and acts as a central source of multidisciplinary documentation about care given in the last days of life. The Department of Health’s End-of-Life Care Strategy (DH 2008), which seeks to ensure equitable access to excellent palliative care nationwide, recommends the use of the LCP across all healthcare settings as a means of providing a high standard of care in the last days and hours of life.

The LCP, and indeed all good palliative care, always integrates physical, psychological, social and spiritual aspects of care, at no time more important than in the terminal phase of life. Some principles of care are outlined for each of these areas below.

Physical care

Table 2.1 lists the most common physical symptoms present during the terminal phase of life and any management changes specific to care of the patient who is dying. The first four symptoms are the most common.

Psychosocial care

Ongoing psychosocial assessment, support and care of the patient and their relatives are extremely important as death approaches. However, provision may need to be adjusted according to the changing needs of the patient – many will experience increasing anxiety and distress, increased feelings of social isolation and, alongside this, a decrease in physical energy available to them for dealing with these concerns. Relatives will naturally be distressed by the increasing illness of the patient and may exhibit signs of grief even before death occurs. Nurses should ensure that, wherever possible, the physical environment is conducive to patients and relatives being able to express their thoughts and emotions, and that appropriately trained staff are available to listen and support them.

Preferred priorities of care

An important aspect of meeting the psychosocial needs of patients and their relatives in the last days of life is to ensure that, wherever possible, preferred priorities of care are discussed and met. These include preferred place of care and death and other difficult issues which have traditionally not been discussed, to the detriment of the patient. A formal document, developed as part of the Department of Health’s End-of-Life Care Strategy (DH 2008), is available to support these discussions (www.endoflifecareforadults.nhs.uk).

Spiritual and religious care

As death approaches, many people will be seeking answers to life’s big questions: its nature, meaning and purpose and what, if any, form it takes after death. Some may find these answers in religion, others in their own philosophy or that of others. Many nurses acknowledge the struggle to provide spiritual or religious support because they feel inadequately skilled or knowledgeable (Kissane and Yates 2003). However, assessment, even if simple, communication and onward referral will ensure that appropriate care can be given without compromising the integrity of the healthcare professional, nor denying the patient the opportunity to explore these central life issues.

Those with specific religious beliefs may have certain religious practices which need to be undertaken before or after death. It is important to try to discuss these with the patient, as even where relatives share a common