There are more than one million people living with chronic obstructive pulmonary disease (COPD) in the UK. COPD does not follow a predictable course and differs from person to person. It is often difficult to determine the stage that a person has reached in the condition: while some patients will present with a gradual decline, others may remain stable for years, and some will require hospital admission for respiratory support. The uncertainties around the nature and progression of COPD make decisions about end-of-life (EOL) and starting EOL care challenging. This article explores some of the indicators of decline in a person with COPD, including exacerbations, cognitive dysfunction, sarcopenia, depression and anxiety. It also discusses the importance of starting appropriate EOL discussion with patients, as well as the many benefits of multidisciplinary team working when it comes to recognising care needs and enhancing patients’ quality of life.
Caring for those who are dying and in the last days of life is a common aspect of caring for people in the community. While caseloads are time-pressured, stretched nurses can do a great deal to reduce any suffering at the end of life by providing optimal assessment and care. An important feature is that nurses first need to be able to identify when death is likely. They need sensitivity and to be able to build a therapeutic relationship with the patient and those significant to them. Nurses play a key role in providing and coordinating quality care and comfort, for which good communication skills are essential. Assessment and interventions to manage pain and symptoms, as well as helping to prepare patients and their families for death, are important. Community nurses can also direct family members to relevant resources and specialists, including those for bereavement.
This article reports on the monitoring of healing rates of fullthickness pressure ulcers at one care provider in the Midlands. This was an agreed measure that was part of the Commissioning for Quality and Innovation (CQUIN) incentive scheme for the CCG. It was an attempt to provide data to support the anecdotal reports that pressure ulcer healing rates had improved after the implementation of a pressure ulcer reduction scheme called the Midlands and East Pressure Ulcer Ambition in 2012. The healing times for full-thickness pressure ulcers were recorded at 40 and 80 days after being reported by the community care provider (a community interest company [CIC], providing NHS funded services). There were 138 patients included in the data collected over a one-year period in 2015. A total of 34% of the patients were healed or healing at 40 days. A total of 55% of patients were healed or healing at 80 days. Of the 138 patients who had a full-thickness pressure ulcer, 56 died (41%), 15% had deteriorating or static wounds at 40 days and 9% at 80 days. This demonstrates that the majority of full-thickness pressure ulcers progress to healing unless the patient is at the end of life. There should be a continued emphasis on preventing as many pressure ulcers as possible to reduce avoidable harm to patients.
This article discusses the considerations and actions taken to facilitate the discharge of a ventilated end-of-life patient called Michael, whose name has been changed for confidentiality, from a critical care unit (CCU) to his expressed preferred place of care. It focuses on how the district nurse (DN) and the single point of access (SPA) for end-of-life care teams by working between primary and secondary care services and across organisational service units were able to facilitate this discharge and achieve the wishes of Michael to die peacefully at home. For all services involved, this proved to be a complex discharge and following completion of the care episode a root cause analysis was undertaken to capture the lessons learnt and advise the CCU at a services debreif how discharges to the community from the CCU could be improved.
The provision of end of life care is important core work for community nursing teams. Once end of life has been recognised, a focus on palliation of symptoms and an emphasis upon assisting people to ‘live well until they die‘ becomes paramount. Breathlessness is a common distressing symptom for patients, significantly affecting their quality of life and is sometimes the cause of unnecessary admissions to hospital. This article explores the pathphysiology of breathing and breathlessness and offers some thoughts on history-taking and physical assessment, skills that nurses in advancing practice roles are now undertaking in the community setting to enhance the care they deliver to patients. This article aims to support community nurses to gain knowledge to inform the provision of effective evidence-based care and assist patients and their families to manage breathlessness at end of life.
