Nutrition and hydration in the last year

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80 year old patient (Mrs Bessie Wilson) just diagnosed with advanced gastric cancer. Prognosis of weeks to months. DN visiting husband of patient and has visited to do leg ulcer dressing. Husband (Freddie) and son (Jay) also in the room.

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Use of name - not assuming first name appropriate Adopting the SPIKES (Baile &Buckman et al 2000) model -and although the DN was not visiting to specifically deliver "bad news", in this situation she can adopt the principles of this model as she was reiterating and clarifying as best she could with the limited information she had.

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Common that not all information is remembered in the same way or understood by two people. Common that family members do not understand the reduced need or desire for food (Del Rio et al 2012). DN will be assessing how family members are coping and who is understanding what of the situation

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Providing families and patients with information relevant to nutrition and hydration is helpful. Timely communication that is appropriate to individual needs is required.

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Empathy. Listening to the patient and assessing their different perspectives on the situation- and appreciating the consequences of not gently providing honest information.

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Empathy
Assessing how food is being tolerated
Practical advice welcomed by families (Bazian report)

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Often, patients will minimise symptoms

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DN facilitating open communication
Providing practical advice: show 7 Ps

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Facilitating an understanding of the natural process of reduced desire for food
Checking out it is ok with the patient
Check the RCN guidance on Nutrition

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DN observing and assessing family understanding of the situation and response to illness
Picking up on cues from Bessie

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Providing practical advice - making a plan of how to get the support required

Empathy Supporting a plan with goal setting Checking understanding - providing the opportunity to ask if they have questions

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This conversation has shown how the DN has used good communication skills to support the family to understand the seriousness of the situation and also to facilitate practical support re nutrition and hydration
Elements of the SPIKES model were used eg.
Obtaining patient perception, checking out understanding, using language that is understood, summarising, displaying empathy, respect name and how DN addressed the patient

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This demonstrates the value of facilitating such an interaction when there has been potential conflict brewing. Reflection from survey "My experience is that patients and carers really need our support and communication, a listening ear, kindness, empathy, compassion, tender loving care are still qualities that are needed alongside knowledge and skills. District nurses who care and get to know their patients in the palliative stage, care goes more effectively at end of life.” ID 1305

All patients should be offered food and drink of adequate quantity and quality depending on their ability to take it, and also to any assistance they need to eat and drink. Malnutrition and dehydration can be both a cause and consequence of ill health, so maintaining a healthy level of nutrition and hydration can help to prevent or treat illness, symptoms and improve treatment outcomes for patients. It is important to keep the nutrition and hydration status of patients under review. You should be satisfied that nutrition and hydration are being provided in a way that meets your patients’ needs, and that if necessary patients are being given adequate help to enable them to eat and drink.

If you are concerned that a patient is not receiving adequate nutrition or hydration by mouth, even with support, you must carry out an assessment of their condition and their individual requirements.

You must assess their needs for nutrition and hydration separately and consider what nursing care actions are required and document your assessment and actions in the individuals end of life care plan.
As part of your assessment you should consider if there is a need for artificial nutrition and/or hydration and discuss this with the doctor and multidisciplinary team.

If you think the person requires a further assessment of their nutritional needs, make sure you report this to the person in charge of their care.

Nutrition and hydration in the last few days

All patients are entitled to food and drink of adequate quantity and quality, and also to any assistance they need to eat and drink.

Needs will change in the last few days as the body’s processes slow down and stop.

If you are concerned that a patient is not receiving adequate nutrition or hydration by mouth, even with support, you must carry out an assessment of their condition and their individual requirements.

You must assess their needs for nutrition and hydration separately and consider what forms of clinically assisted nutrition or hydration may be required to meet their needs.

As the dying person’s ability to swallow and the plan of care changes it is essential that this is explained to the relatives and communicated to all care staff including ward volunteers/ housekeepers/ward clerks and catering staff.

Where a patient has become mainly unresponsive and their prognosis is expected to be short days or hours, the care team with the patient/relative/LPA may agree that comfort measures only should be the main focus of care and decisions will need to be made as to when to stop giving oral nutrition and oral hydration as the risk and distress caused to the dying person outweighs any potential benefit.

Sensitive communication may be required about why a drip may or may not be needed in the last few days of life.

When death is close at hand

Not everyone will display all of the signs but this is often how the body prepares for the final stages of life:

Below is a clip that demonstrates how vital it is for staff to explain when intravenous fluids are no longer appropriate.

Changes in the last year

As the individual approaches the end of their life their body will undergo changes in the last year. It is important that you are aware that their condition is not fixed but look out for any changes and respond to their needs by adapting the care you deliver.

Signs of approaching death Advice
Sleeps more and difficult to wake at times Plan conversation times for when the person seems more alert.
Loses appetite and may ‘forget’ to swallow Offer small servings of favourite foods or drink without forcing. At this time the body has minimal needs.
Becomes confused about time or may not recognise familiar faces Speak calmly. Remind the person of the day, time and who is in the room.
Becomes restless, pulls at bedclothes, has visions of people or things that aren’t really there. They may develop a fixed stare Leave a soft light on in the room. Provide reassurance and avoid physical restrictions where possible. Even if the person cannot respond, don’t assume they can’t hear you – hearing is the last sense to be lost.
Loses control of bowels or bladder This does not usually occur until death is close. The amount of urine will decrease or stop as death nears. The district nurse can advise on how this can be managed.
Secretions collect at the back of the throat and sound like a rattle This is because the person cannot swallow saliva but does not mean they are uncomfortable.Turn the person on their side or raise the head of the bed. Sometimes medication can be given to help – ask the district nurse or your community nurse.
Arms and legs cool as the circulation slows down. Sometimes one side of the body will be warm and the other cold. Face becomes pale and feet and legs adopt a purple-blue appearance Use just enough coverings to keep the person comfortable.
Breathing becomes irregular and even stops for short periods. The pulse becomes fast and irregular There is no need to become alarmed about this. It causes no distress to the patient.

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