End of Life

Policy Statement

Warwick Park House recognises that service users who are suffering from terminal illness and who are in the last stages of that illness need total care, including emotional care and frequent attention.

Warwick Park House adheres fully to the Essential Standards of Quality and Safety 2010 and NHS Devon & Devon County Council- Dying Matters in Devon. The home is proud to supports The Six Steps St Luke’s philosophy of care. Warwick Park House Limited is a Nursing Home with Registered Nurses on site 24 Hours a day. Some of our service users care for by Key Workers who are experienced carers and lead the team caring for people assessed as requiring a Residential Level of Need.

Aim of the Policy

This policy is intended to set out the values, principles and policies underpinning Warwick Park House approach to holistic care to dying and death.

Mental Capacity Act

The Mental Capacity Act and Safeguarding Adult agenda are relevant to End of Life Care. The Mental Capacity Act provides the legal framework for decision- making when a person may lack capacity to make these decisions. Wherever possible the person should be enabled to reach appropriate decisions by themselves.

Where this is not possible, the Act offers guidance to ensure that those empowered to make decisions on behalf of someone else – including family members, carers, health and social care professionals and attorneys, always act in the best interests of those who lack mental capacity- this can be the case when someone is suffering with dementia.

The Mental Capacity Act provides the mechanism for people to complete Advance Care Plans (a clear instruction refusing some or all medical procedures) and Advance Statements (an indication of the person’s wishes).

The aim is to ensure that people who may be vulnerable to abuse or harm are protected by services which ensure that peoples’ human rights are respected.

Clients may have “advanced care planning” (ACP) wishes which we respect.

Treatment Escalation Plans – (TEP) forms are kept at the front of the care plan. The original travels with the service user should they leave the Care Home for hospital visits /appointments or specialist care.

All transfers to emergency or urgent care from the home are undertaken with a Registered Nurse overview. The Registered Nurse will check forms and counter sign information. The Key Worker assists with information, but the Registered Nurse manages the transfer of information and procedure to support.

Advance Care Planning

Advance Care planning is key means of improving care for people nearing the end of life and of enabling better planning and provision of care, to help them live and die in the place and the manner of their choosing. The main goal in delivering good end of life care is to be able to clarify peoples’ wishes, needs and preferences and deliver care to meet these needs.

Advanced Care Planning is encouraged prior to admission, but can take place at any time. Advanced Care Plans can be changed and reviewed at any time viewed appropriate. Advance care planning is in essence an important yet simple conversation that can change practice and empower patients. It can be a process of discussions over time, a ‘relationship’ discussion with regular reviews and can helps catalyse deeper communication between patients and their families and loved ones.

It need not be ‘over medicalised’ or too formalised, and could be undertaken by any involved in end-of-life care, though is best undertaken by experienced trained staff who know the person well, such as GPs, community nurses, care homes staff and specialists.

It should be included consistently and systematically so that every appropriate person is offered the chance to have an advance care planning discussion with the most suitable person caring for them.

The process of Advance care planning includes many elements – essentially helping people approaching the end of their life to describe and clarify: –

  • What they want to happen
  • What they don’t want to happen
  • Who will speak for them?

Effective communication within and between the multidisciplinary team, service user, family, friends and staff will be sensitive and honest and reflective, but primarily to the service user’s needs. Care Home staff share information through daily handovers and care plan sharing of information. All staff are encouraged to share information and concerns.

End of Life Identification and Early Assessment

The Gold Standard Framework Prognostic Indicator Guidance is used as guidance by Nursing Staff and key workers to aid identification of service users’ wellbeing and to support earlier recognition of patients nearing the end of life.

Staff are encouraged through training to familiarize themselves with this tool and trigger questions. Three triggers that suggest that patients are nearing the end of life are:

  • The Surprise Question: ‘Would you be surprised if this patient were to die in the next few months, weeks, days’0?
  • General indicators of decline – deterioration, increasing need or choice for no further active care.
  • Specific clinical indicators related to certain conditions.

For further information: The Gold Standards Framework Centre info@gsfcentre.co.uk www.goldstandardsframework.org.uk – A copy is held in the Nurses Office.

Warwick Park House Limited are dedicated end of life care services and encouraged partnership with local services to deliver integrated care for people with end-of-life care needs.

We work with local partners to support seamless services for our service users. Throughout the different stages of need.

We enable options and choice and information, supporting and enabling shared decision making to improves the experience of the end-of-life care and help people to decide between different options for care, including their preferred choice of place of death, before they get there, supporting planning ahead, no surprises. We enable individuals to ‘change their mind’ if they so choose.

An early assessment of a potential resident’s needs and wishes as they approach the end of life is vital to establish their preferences and choices, as well as to identify any areas of unmet need. It is important to explore the physical, psychological, social, spiritual, cultural and, where appropriate, environmental needs and wishes of each resident.

We undertake a holistic assessment for end of life needs and preferences in partnership with residents and, where appropriate, relatives and friends. This is usually prior to admission. When the point comes that a resident enters the dying phase key staff will recognise the signs and symptoms and take the appropriate action, respecting the wishes of the individual. Sometimes these phases can happen unexpectedly and quickly without warning. Our staff will act professionally when managing urgent and emergency situations.

There may be circumstances where 999 paramedic support is required. The Registered Nurse or Key Worker may make this decision in the best interests of the service user.

Policy on Death and Dying

The staff will be aware of the service user's condition and be in contact with the service user's GP to ensure that the service user is in the best possible place and to provide the care required.

Following an agreed indication of End-of-Life decision the team in conjunction will make a care plan for End-of-Life management and support.

Any specific arrangements surrounding the death of a service user, e.g., religious rituals before, after or at the point of death, will be documented and staff will be aware of such arrangements. The service user’s GP or relatives may be able to advise in these cases.

Clients receiving care from Warwick Park House Limited will be receiving multidisciplinary care support during end-of-life support. To successfully share information and ensure safe, and appropriate care is provided clients are likely to be placed on the Palliative- End of Life Care Register which features, easy to access to real-time patient care plan information. Sharing information ensures effective implementation of Advance Care Planning and identify patients approaching end of life, recording their preferences and making this available across services and agencies 24 hours a day, seven days a week to ensure adherence to the patient’s preferences.

  1. The involvement of family and close friends is essential to the wellbeing of the service user. Visiting will be encouraged and close family members will be given the opportunity to stay overnight and to eat with the service user.
  2. Staff will encourage a relationship of trust and allow Warwick Park House to be more responsive to the service user’s needs.
  3. Staff will spend time listening and talking to the service user as well as caring. They will respond directly to requests for arrangements to be made so that the service user feels that things are put in order before his or her death.
  4. Extreme care will be taken when caring for an unconscious service user. Staff will be aware that an unconscious service user may still be able to hear and be aware of the presence of someone else in the room and so care will be taken not to discuss the service user’s condition within the room.
  1. The service user will be made as comfortable as possible and his or her comfort will be checked regularly.
  2. Warwick Park House acknowledges that cleanliness is important and the continuation of a daily bath will be maintained for as long as possible.
  3. A normal routine will be continued with respect to hairdressing, shaving, chiropody, etc unless the service user expressly wishes this not to be so.
  4. Care will be taken in relation to the prevention and treatment of pressure sores, oral hygiene and dehydration.
  5. Any aspect of personal holistic care needs will be encouraged to be brought to staff members and every effort will be made to achieve peace and comfort.
  1. Frequent small refreshing drinks will be given so that the service user consumes enough fluid and doesn’t dehydrate.
  2. If solid food cannot be tolerated, liquidised food, soup or a food supplement will be offered to the service user.
  3. The service user will be allowed to enjoy a favourite food or drink, eg chocolate or a glass of beer or whisky, if they wish.
  1. As far as possible the dying resident should be kept free from pain.
  2. The service user’s GP will be consulted to advise on what kind of painkillers the service user wants or needs.
  3. Pain management is provided in a number of ways and is planned with the service user and family in the most appropriate way to meet individual needs.
  4. The staff should be aware of the degree of pain being experienced by a service user using the appropriate assessment tool for the individual service user. (The Universal Pain Assessment Tool- Wong Baker Facial Grimace scale/ Behavioural Pain Assessment and Dis DAT Assessment Tool and Numeric Graphic Rating Scale and Verbal descriptor rating scale are most commonly utilized) Having many differing diagnoses including physical needs, mental health needs including dementia, educational abilities and symptoms our Registered Nurses may utilise one or more assessment tool to assess and support individuals. We adapt to meet the needs of our service users.
  5. Specialist and Palliative Care team involvement and support is encouraged for advice and guidance.
  1. Support will be provided for those staff caring for terminally ill service users. Staff should feel that they can discuss their feelings and experiences with other staff members, perhaps as part of a weekly staff meeting.
  2. Staff will make sure that they treat the dying service user like any other service user, affording them the same amount of care and attention.
  3. Staff will not purposefully avoid awkward conversation. Staff may feel that by talking naturally to a service user they are being insensitive to the situation, but this is rarely so. The service user needs to feel that he or she can talk about his or her forthcoming death, if he or she wishes.
  4. Staff will try to answer all of a service user’s questions. Staff will not selectively decide to ignore difficult remarks or questions. If the carer is unable to answer medical or religious questions, these will be referred with the service user’s knowledge to a more qualified person.
  5. Staff will make sure that the service user is not isolated from interacting with other service users within Warwick Park House unless it is his or her wish to be alone.
  1. Staff will encourage relatives and friends to visit as often as possible and at any time.
  2. Relatives will be offered emotional comfort and support and be given the chance to share their fears and experiences with caring staff. This will help both staff and relatives come to term with the death.
  3. Staff will find out whether a relative wishes to be contacted if the service user deteriorates or dies during the night.
  4. Relatives will be offered meals and refreshments if they are sitting with the service user. There will also be the offer of accommodation during the night if the relative wishes to stay with the service user, or a comfortable chair and blanket if nothing else should be provided.
  5. Staff will make sure that the relative is kept informed and completely up to date with the service user’s treatment and condition and facilitate discussion with the service user’s GP if necessary.
  6. If a relative wishes to become involved in caring for the dying person, staff will make every effort to incorporate this into the daily routine, e.g., if a relative wishes to help feed the service user or help the service user to bed for the night the relative will be made aware of the service user’s normal routine and will be encouraged to participate.
  7. Other service users may wish to share in the companionship of the dying resident and it is important that they are not excluded. It is essential that they realise that death within Warwick Park Houses shared and that they in turn will be loved and comforted if necessary.

When Warwick Park House Limited has accepted a service user it has been acknowledged they are able to meet the individuals religious, spiritual and cultural needs. The Registered Manager is made aware of all admissions and service users’ needs.

Warwick Park House Limited has strong links with local clergy who are able and willing to attend to support service users and their loved ones. The Keyworker and Registered Nurses will offer to contact religious supports and welcome preferred religious representatives or clergy from local parishes.

Family and friends wishes will be supported as long as they honour the service users wishes who is our primary focus. Where ever there are differences of spiritual and religious feelings and beliefs we will aim to support both perspectives whilst maintaining respect for the service user. We recommend Advanced Care planning in these circumstances to ensure all expectations are fulfilled and considered.

In the event of a religious or cultural need being brought to our attention following admission every effort will be made to support the service user and their family. If a religious or spiritual need cannot be met both the service user and family will be informed as soon as possible.

Many of our relatives and friends of Warwick Park House have built relationships with staff during the time their loved one has been cared for with us. Many local families return to Warwick Park House and use us as part of the aging family process. Bereavement can be a difficult time and is managed individually.

Bereavement support is available from our Registered Nurses. Many enjoy a visit to Warwick Park House and have placed ornaments, plants flowers in the Memorial Garden for years after their loved ones have departed. Our garden is a peaceful little oasis in the area. The sun often shines in this very special place. The anniversary of the passing of a loved one or birthday is often a moment of reflection when family members like to return. Relatives and friends are signposted for specialist assistance and are reminded our tea and coffee facilities are always available. Leaflets are left out for family and friends to help themselves. Warwick Park is a friendly welcoming accessible comfort for the local community.

Warwick Park House Limited is proud to encourage a learning environment for all staff and are particularly proud of the high percentage of NVQ qualified and learners. An electronic training log is maintained by the Registered Manager. All new staff should read the policy on dealing with a dying a service user as part of their induction process. Recruitment of staff is subject to the potential employee agreeing to ongoing learning with the Company. Carers are encouraged to complete the Level 2 End of Life Courses available through the Care Home and enjoy the ongoing learning within the home to improve the quality of life for our service users. It is respected “death” and dying matters can impact on staff individually due to personal and past and present circumstances. Sensitivity and compassion includes staff needs. The ‘home’ is the ‘staff’. Warwick Park House acknowledge the need to value and care for its staff to ensure staff may share compassion with the service users and their families.

We welcome learning from experience and value feedback from family and friends.

This policy will be reviewed annually.