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Palliative and end of life care: information for health and social care professionals
This policy for the Harrogate and District locality has been developed in response to a number of requests from patients and carers in to be able to administer subcutaneous medication in a palliative care setting.
A similar policy for the Scarborough, Ryedale and York localities is available, here, together with a Carer Medication Diary Template, here.
York Teaching Hospital has produced some guidance for healthcare professionals on the prescribing of anticipatory medication in palliative care.
This guideline covers Harrogate and District NHS Foundation Trust (HDFT) and York and Scarborough Teaching Hospitals NHS Foundation Trust (YSTHFT) (hospital and community setting). This guideline supports the use of subcutaneous fluids in palliative and end of life care.
This leaflet is for people who have an implantable cardiac defibrillator (ICD) and may be helpful also to their family or close friends. It discusses when it may be best for you to have the shock function of your ICD turned off (deactivated). It may be important to consider this if you develop a terminal illness, become very frail or decide that you no longer wish to receive shocks from your ICD.
The DNACPR decision is important since it concerns a person’s choice as how to pass the closing days and moments of his/her life, and how they manage their death. The patient’s wishes in these matters are an expression of their right to determine their own destiny. A form for adults and young people over the age of 16 is available to download, here.
Resources to help clinicians make these important decisions with patients and their families / carers are available to download, here:
The prime aim of all treatment at this stage is the control of symptoms, current and potential. There’s detailed information about symptom control for health professionals, here.
Please find guidance on the treatment of patients no longer able to take oral maintenance methadone in last days/weeks of life.
Harrogate and District NHS Foundation Trust has also produced Guidance to accompany Medical and Nursing Care Plans for Last Days or Hours of Life.
Colleagues at York and Scarborough Teaching Hospitals NHS Foundation Trust have also produced Options for symptom management in last days if there is no syringe driver or manpower to give injectable drugs, in light of the COVID pandemic.
Advice and guidance from Harrogate and District NHS Foundation Trust is available, here.
These guidelines have been prepared to help health care professionals in Harrogate and Rural District to provide supportive and palliative care to patients with heart failure (HF) with particular regard to symptom control.
This guidance from Harrogate and District NHS Foundation Trust applies to all clinical staff in Harrogate and Rural District who care for adult palliative care patients.
See also: Topical Morphine for painful wounds guidance from HDFT.
An opioid conversion chart for professionals referring into Harrogate and District NHS Foundation Trust is here. You may also find this opioid conversion chart from the York and Scarborough Hospital Trust useful.
An opioid substitution treatment pathway for patients no longer able to take oral maintenance methadone in last days/weeks of life is available, here.
A number of pharmacies are commissioned to provide a locally agreed list of medicines that may be necessary in palliative care. These pharmacies make a commitment to ensure that the users have prompt access to these medicines when presented with an NHS prescription, during the pharmacies contracted opening hours.
Please note: Other pharmacies may routinely stock many, if not all, of these medicines as part of their usual dispensary stock.
In the event of there being insufficient stock to fill an immediate need, the pharmacy will liaise with another community pharmacy. The pharmacy will aim to locate a pharmacy with sufficient in-date stock and request that they reserve the stock for collection by the user. If no further stock can be located the pharmacy will contact the prescriber to discuss a suitable alternative.
Click here for a list of the pharmacies commissioned to provide this service in North Yorkshire as of 23/03/23.
Click here for the palliative care drugs scheme list of drugs and quantities stocked.
This formulary is a guide for prescribers in hospitals and primary care across the Scarborough and Ryedale locality. The acceptance and use of this formulary will enhance the quality and consistency of palliative care.
Click here for referral criteria.
Following feedback from professionals, patients and their families, Resuscitation Council UK has improved the ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) process which supports conversations about care in a future emergency. You can read more, here.
Following several serious incidents relating to prescriptions of Dexamethasone, please find below some key practice points:
Steroids may be used in palliative care for symptom control
Dexamethasone is usual steroid of choice in palliative care.
Dexamethasone 6mg is equivalent to Prednisolone 42mg (6mg x7) orally.
Most indications are “off label” and potentially have serious side effects g.
increased susceptibility to infections
Always document in/on the medical notes, drug chart and EDN
indication for steroids
plan for review or down titration.
Keep to short courses and lowest effective dose.
Review after 5 days when starting steroids if no benefit, stop.
If benefit, reduce to the lowest dose that sustains benefit and plan for on-going review.
Limit course of steroids to < 3 weeks, where possible, as can be tapered fairly quickly within this duration;
Longer courses > 3weeks will require slower and more prolonged tapering.
Consider a PPI for the duration of steroid course, review need for PPI when steroids stop
Do not discharge patients on steroids without a clear plan
Patients on high dose steroids will need clear instructions for reduction
Discharge letters should always provide
plan for steroid reduction/ review
clear designation of who is responsible
time frame for when this should take place
When commencing steroids in hospital or in the community
- Measure a baseline blood glucose in patient not known to have diabetes or diet control diabetes
- If blood glucose <11.1mmols they should be educated on the risk of steroid induced hyperglycaemia and possible symptoms discussed (tiredness, fatigue, thirst, dry mouth, frequent need to pass large volumes of urine, genital thrush, blurred vision)
- If they experience these symptoms they will need to be given a blood glucose machine and to monitor once daily pre evening meal as blood glucose tend to run high during the day and reverts to single figures the next morning
- If blood glucose >11.1 mmols patient should be given a home blood glucose monitor to test for steroid induced hyperglycaemia and same guidance above re symptoms
- For known diabetics on oral hypoglycaemic agents (OHAs) and/or insulin who are already monitoring their blood glucose at home need to be informed of steroid induced hyperglycaemia and need to monitor more closely pre meal and pre bed
We would be aiming for diabetic control 6 to 16 mmols
- If blood glucose levels run >16mmols for more than two occasions in a 24-hour period in any of these groups of patients then start or increase diabetes medication
- Steroid-induced hyperglycaemia is usually treated with gliclazide tablets or insulin injections
Recommended Dexamethasone starting doses are as follows:
Malignant Spinal Cord Compression
Raised Intracranial Pressure (i.e. brain mets)
16mg OD if severe
8mg OD if mild-mod symptoms
Liver capsule pain
Nausea & vomiting (not related to chemo)
6mg OD subcut
Airway obstruction/ SVCO (whilst seeking specialist advice regarding investigation and definitive management)
A new set of guidelines for subcutaneous-Furosemide (developed by colleagues in Harrogate and York Hospital Trusts) is available here.
Please see attached for healthcare professionals in North Yorkshire and York.
This protocol covers all inpatient and community services within Harrogate and District NHS Foundation Trust.
Clinicians may find the attached leaflet, produced by colleagues at South Tees Hospitals NHS Foundation Trust, useful.
This leaflet (from York and Scarborough Teaching Hospitals NHS Foundation Trust and adopted by Harrogate and District NHS Foundation Trust is a guide to the pharmacological management of symptoms experienced by patients with advanced kidney failure. It is intended to be used when dialysis is not the preferred management option, and the focus is on symptom control.
This guidance for medical professionals from the Yorkshire and Humber Palliative and End of Life Care Groups covers some of the commonest symptoms in cancer and advanced progressive disease. For the management of other symptoms not included here, including fatigue, cough, sweating, anorexia and cachexia please see an introductory palliative care text and refer to the other useful resources listed in the introduction.
These guidelines have been written by a multidisciplinary team of specialists and generalists to support any clinician responsible for the management of symptoms in patients with palliative and end of life care need, regardless of diagnosis.
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Services for patients in Hambleton and Richmondshire
In April 2017, a new end of life service was launched in Hambleton and Richmondshire through a partnership between the former NHS Hambleton, Richmondshire and Whitby CCG, Herriot Hospice Homecare, St Teresa’s Hospice, terminal illness charity, Marie Curie, and South Tees Hospitals NHS Foundation Trust.
Under this scheme, patients receive day time care at home, overnight care, additional equipment at home and supported admission into end of life care in a step-up/step down bed. These beds were introduced as a result of the ‘Transforming our Communities’ consultation.
Eligible patients are those who are assessed to be in the last few weeks of life, or whose condition is rapidly deteriorating. They must be under the care of a GP in Hambleton and Richmondshire.
We have produced a helpful leaflet on the new end of life care service, here.