New guidelines recommend that GPs give patients anticipatory medicines specific to their needs and that assisted hydration should be offered within a community setting if it is thought a patient could benefit from the treatment.
The NICE guidance for dying adults replaces the ill-fated Liverpool Care Pathway, a protocol for looking after people at the end of their lives, which was withdrawn last year after a number of ‘serious failings’ in how it was being implemented were found.
It was important to ‘move away’ from the notion of ‘diagnosing’ a patient as dying and to ensure that any patients thought to be entering their final days is regularly monitored, NICE added. Doctors should be aware that the same symptoms that identify dying could also be signs of a person improving.
GP end of life care
It recommends that a lead healthcare professional who has good rapport with the patient – and who may be the patient’s GP – should be assigned as their lead healthcare professional to inform them what is happening and help raise any concerns on their behalf.
Individualised care plans, shared decision making and clear communication with dying patients is emphasised to ensure patients can die with dignity and comfort – moving away from the Liverpool Care Pathway, which was criticised as a one-size-fits-all system.
The guideline states that patients should be given anticipatory medicines, but only those they may actually need, instead of the ‘set preform’ of treatments for common symptoms at end of life, such as pain, nausea/vomiting, noisy breathing and agitation/delirium.
GP Dr Adam Firth, who was involved in developing the guideline, told GPonline: ‘A key message surrounding delivery of the guideline is around anticipatory prescribing and moving away from the four areas of common symptoms.
‘Rather than that being a set preform of medications that we might use in that situation, a tailored individualised approach recognising what symptoms are likely to occur is needed.’
GP assisted hydration
GPs should provide patients with assisted hydration to patients who may benefit from it medically either orally, intravenously or subcutaneously – even though there is little evidence that this could help prolong their life.
The Liverpool Care Pathway came under fire for leaving many patients dehydrated.
‘The recommendation in the guideline is that GPs should discuss the potential risks and benefits [of assisted hydration] with the patient and their families,' said Dr Firth. 'There's no evidence that by giving fluids we will prolong the dying phase and there's no evidence that by not providing fluids we will hasten the dying phase for people who are already felt to be in their last days of life.
‘For patients who have signs and symptoms that could be linked to dehydration, then there is no reason not to consider giving subcutaneous fluids in the community to help manage those symptoms.’
It is important for GPs to work ‘within their competence’ – and not be afraid to seek expert help from palliative care specialists and colleagues if in doubt, he added.
‘Where necessary, for instance if our management of symptoms isn’t progressing in the way that we would expect, then absolutely seek the advice of specialist palliative care in order to be guided towards the next best steps in terms of managing difficult or complex symptoms.
‘But we’re certainly not suggesting that everyone needs to have access to specialist palliative care in order to have a good death. There's clear discussion within the guidance that supports the on-going delivery of high quality end of life care by GPs.’
A recent report from the Economist Intelligence Unit ranked the UK as having the best end of life care in the world, but NICE said there were still areas for improvement.
Around 500,000 people die each year in England, and three in four of these are expected. Some 60% of these die in a hospital environment.