Case study:

23 June 2009

Maintaining identity and control in Wimborne Care Home, Dorset

Key points

Staff at Wimborne Care Home in Dorset were able to provide support to a resident with bronchial carcinoma and no known relatives during the last three months of his life, so avoiding unnecessary hospitalisation.

All the staff involved had had palliative care end of life training from the local PCT. One staff member was also undertaking the diploma of palliative care. Their expertise combined with having the necessary palliative drugs to hand meant the resident could be cared for in the home and an emergency hospital admission was avoided.

The care

This gentleman had initially been admitted to hospital as an emergency from his lodgings. He had been living with a couple for 20 years who felt unable to cope with his increased needs. He had had no contact with his family – a sister and stepbrother in Essex and a daughter in America – for many years.

On discharge to the home he had only what he was wearing. With his consent two members of staff visited his lodgings, packed up his room and brought back his belongings. Over the course of a few weeks he was assisted to go through his personal papers at his own pace so he could put his affairs in order.

In the month before his death he was escorted to his bank and visited by a solicitor to help him make his will. The home helped him make contact with his daughter on the phone. The two managed to have some quality time reminiscing before his death. The staff were also able to discuss what he wished to do in his remaining time. He decided he did not wish to go back to hospital or have any further radiotherapy. He wanted reassurance that he would not be in pain at the end. It was important to him that he was able to take control of his life.

Two weeks before his death he had been poorly with a chest infection for which he was having antibiotics. Staff discussed his condition with the home’s Macmillan nurse. They then liaised with the GP and the Macmillan nurse to obtain a ‘just in case’ prescription for generic drugs to cover the weekend, these were Diamorphine, Haloperidol, Metoclopramide and Midazolam.

At first he seemed to have recovered from the infection but 10 days later he became unwell again with pyrexia and lethargy. The home requested a GP visit in the morning and informed his family of his deterioration.

In the early afternoon two nurses were with him when he started haemorrhaging. They were reassuring and took control of the situation. Within 5-6 minutes of the haemorrhage they administered an initial single dose of Diamorphine and Midazolam. They then set up the syringe driver with Diamorphine, Midazolam and Metoclopramide. He received another stat dose of diamorphine on the GP’s advice. Within 20 minutes of the first bleed he was in a peaceful semi-conscious state and died in his own room shortly afterwards with staff by his side and as peacefully as possible in the circumstances.

Aftermath

Although the staff were saddened by this gentleman’s sudden death they felt it had been a ‘good death’. It was well-controlled with no panicking or desperate phone calls or unnecessary ambulance call-outs. The feedback from the GP and Macmillan nurse was positive. The Home Manager felt they had achieved this gentleman’s wishes.

The need for free end of life care training for nursing home staff is paramount if this level of support is to be routinely achieved. The challenges are around training, communication and liaising with key professionals to ensure that processes are put in place to think ahead to the end of life. The home now plans to develop a more structured approach to its training and to continue to build relationships with local providers in order to provide supportive end of life care.