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Stroke Palliative Approach Pathway

Objective
This pathway has been developed to guide the multidisciplinary care of stroke patients in
the last hours or days of life. It addresses the clinical and personal needs of the patient, as
well as the needs of carers and is in line with current evidence and best practice in the
areas of stroke and palliative care. The aims of palliative care are to:
Afrm life and regard death as a normal process
Neither hasten nor postpone death
rovide relief from pain and other distressing symptoms
Integrate the physical, psychological and spiritual aspects of care
!"er a support system to help patients live as actively as possible until death
!"er a support system to help patients# families cope during the patients# illness and
their own bereavement
$phold the right of every person to receive good end of life care
This Pathway is intended as a guide and does not replace clinical judgement. All
decision making and changes in care, made in the best interests of the patient
and family or carers, need to be assessed and reviewed regularly by the
multidisciplinary team and communicated clearly to the patient where
appropriate and to the family or carer. The pathway recognises that dying can be
a comple and uncertain process. There may be times when a person lives longer
than epected, or dies sooner than anticipated.
Pathway criteria
This pathway supports an appropriate care approach for stroke patients, implemented once
the multidisciplinary stroke team has considered the clinical situation and the wishes of the
patient and family % carer, and agrees that:
There is an anticipation of imminent death !& an e'pectation of poor prognostic
outcome !& the patient is in a semi(comatosed or comatosed state and not e'pected
to improve, as a result of severe stroke and%or other concurrent co(morbidities.
!sing the care pathway
$ndertake an initial assessment and commence appropriate palliative approaches
according to )ection * as soon as possible after a palliative approach has been
documented by the medical team in the patient medical record.
rovide ongoing care and monitoring according to the clinical domains identi+ed in
)ection ,.
-ach goal should be marked as .A# /Achieved0 or .1# /1ariance0. If a goal is not
achieved this should not be viewed as a negative2 it re3ects that individual care,
assessment and clinical needs of each patient and the needs of the family and carer
are being regularly assessed and met.
If a 1ariance .1# is recorded, document the reason for the variance in the patient#s
medical record.
The appropriateness of interventions should be assessed for each individual patient.
Treatment protocols for pain, terminal restlessness and agitation, respiratory tract
secretions, nausea and vomiting and dyspnoea are included at the end of this
pathway documentation.
Also note"
4radma label
Insert logo here
/&esi5e as re6uired0
The )troke alliative Approach athway should remain in the medical record.
This pathway replaces the Nursing 7are lan
The Stroke Palliative Approach Pathway for the dying patient is based on the #$P document designed by the
#$P $entral Team,
%arie $urie Palliative $are &nstitute '%$P$&#(
Section ). &nitial assessment and initiation of palliative approach
The nurse caring for the patient should complete this section as soon as medical sta* have documented
in the patient medical record that a palliative approach is to be adopted
+iagnosis
)troke
diagnosis !nset 8ate
!ther signi+cant
diagnoses
resenting
symptoms
8ate referred to palliative care service
8ate pathway
commenced Time
,oal )" -on.essential medications are discontinued and medication is prescribed for common
symptoms which may arise
7urrent medications assessed and non(essential
medication discontinued Achieved 1ariance
arenteral route of medication delivery prescribed /for those not able to
swallow oral medication Achieved 1ariance
)yringe driver commenced if
re6uired and appropriate
e6uipment available
8ate
commenced
Time
commenced
&N comfort medication written up on I*, for the following /see protocols at the back of care pathway for guidance0
/Anticipatory prescribing of these medications will ensure there is no delay in administration if the symptoms do occur0
ain Agitation )ei5ure activity
Nausea and
vomiting
&espiratory tract secretions 4reathlessness 7onstipation
7omfort medications readily available or ordered
from pharmacy Achieved 1ariance
,oal /" The patient0s need for current interventions has been reviewed by the
multidisciplinary team
Interventions reviewed:
Antibioti
cs N%A

8iscontinued 7ontinued
I.1.
cannulae N%A 8iscontinued

7ontinued
1ital
signs N%A

8iscontinued 7ontinued
I.1. % ).7
3uids N%A 8iscontinued

7ontinued
4lood tests /inc. blood sugar
monitoring0 N%A 8iscontinued

7ontinued
9imitation of medical treatment form completed including information regarding not for
:-T call /insert :& no0 Achieved 1ariance
ossibility of a reportable death to the coroner identi+ed as per /insert hospital
procedure number0 Achieved 1ariance
,oal 1" The patient0s skin integrity is assessed

Achieved

1ariance
Assessment of skin integrity as per :elbourne ;ealth ressure $lcer revention Assessment and lanning <orm /insert :&
number0
7onsider use of aids /e.g. pressure relieving mattress0. <re6uency of repositioning should be determined by patient#s condition
and regular skin inspection.
,oal 2" The provision of nutrition is reviewed by the multidisciplinary
team

Achieved

1ariance
!ral food and 3uid for comfort % patient en=oyment, at safest consistency
-ducate family and carers that a reduced need for food is a natural part of the dying process
,oal 3" The patient is able to take a full and active part
in communication $nconscious

Achieved

1ariance
&ecord primary
language
Interpreter
re6uired >es No
atient has an advance
care plan >es No
atient has a :edical ower of
Attorney >es No
Nam
e &elationship Tel no.
!rgan % tissue donation discussed with patient % family if appropriate /insert hospital
procedure number0 >es No
atient has e'pressed wish for organ % tissue
donation >es No
If the patient is unable to take an active part in these discussions the Australian !rgan 8onor &egister can be accessed to
identify if they have previously e'pressed a wish regarding donation. This can be accessed through the 9ions -ye 4ank
7oordinator ?@?A BC?*@A
4radma label
,oal 4" The family 5 carer is able to take a full and active part in
communication

Achieved

1ariance
&ecord primary
language
Interpreter
re6uired >es No
,oal 6" The patient has been able to epress their
religious 5 spiritual needs $nconscious

Achieved

1ariance
7onsider if the patient has any speci+c religious or spiritual needs that need to be addressed /insert ;ospital rocedure
number0
astoral care
contacted >es No
Nam
e 7ontact no. 8ate % time
,oal 7" The family 5 carer has been able to epress their religious 5
spiritual needs

Achieved

1ariance
7onsider if the family or carer has any speci+c religious or spiritual needs that need to be addressed
,oal 8" 9amily 5 carer understand that the goals of care are now
palliative

Achieved

1ariance
<amily % N!D concerns are identi+ed and documented
Identify how family % N!D are to be informed of patientEs imminent death
At any time Not at night time ;rs )tay overnight at hospital
rimary
contact Name &elationship Tel no.
)econdary
contact Name &elationship Tel no.
<amily % N!D given hospital information /e.g. car parking, visiting times, any other
relevant
information, ward clerks aware that family may be staying after visiting hours,
valuables taken home0 >es No
,oal ):" %ultidisciplinary team is aware that the patient is now for a
palliative approach to care

Achieved

1ariance
:ultidisciplinary team noti+ed by group page /insert pager number if appropriate0 of commencement of palliative approach
&f you have charted a ;ariance please complete reason for variance in the patient medical record
<ealth
Professional
Signature
+esignati
on +ate -ame
Section /. Ongoing care and assessment
%ark =A0 Achieved or =;0 ;ariance for each goal +ate" +ate"
> if ;ariance =;0 document reasons and management
in the patient medical record
-5+ A% P% -5+ A% P%
,oal )/" The patient does not have pain
atient does not verbalise or show any signs of pain. !bserve for
non(verbal clues. If in pain consider position change and % or
analgesia.
,oal )1" The patient is not agitated
atient does not show any signs of delirium, terminal anguish,
restlessness % thrashing, plucking, twitching. -'clude retention of
urine or constipation as cause. If agitated consider need for
positional change.
,oal )2" The patient does not have ecessive
respiratory tract secretions
7on+rm that I1 3uids are discontinued. Anticholinergic given as
re6uired. 8iscuss symptoms with family % carer and o"er
reassurance. 7onsider need for positional change.
,oal )3" The patient is not breathless
An'iolytic % opioid given as re6uired. 7onsider need for positional
change.
,oal )4" The patient does not have nausea
7on+rm enteral feeding is discontinued. Five anti(emetic as
re6uired.
,oal )6" The patient does not have bowel problems
4radma label
7hart bowel actions daily. Five aperients as re6uired.
,oal )7" The patient does not have urinary problems
Initiate urinary catheter only if patient is in retention. rovide pads if
incontinent.
,oal )8" The patient0s comfort and safety regarding
medication is maintained
:edications are given as per /insert hospital :& number of
medication chart0 (if medication not required please record as N/A).
If syringe driver is in progress check at least @ hourly and record on
I*, -
,oal /:" The patient0s personal hygiene needs are
met
atient is clean and comfortable. &elatives are included in care of
patient if appropriate.
,oal /)" The patient0s mouth is moist and clean
&egular mouth care is attended to. If appropriate educate family in
regard to mouth care.
,oal //" The patient0s skin integrity remains intact
Assess skin integrity as per /insert hospital :& number of pressure
care chart if applicable0. 7onsider need for pressure relieving air
mattress.
,oal /1" The patient does not have other symptoms
'e.g. oedema, itch(
,oal /2" The patient0s psychosocial 5 spiritual needs
are met
atient is aware of situation and informed of procedures as
appropriate. Touch and verbal communication continued as
appropriate.
,oal /3" The family 5 carer0s psychological 5 spiritual
needs are met
<amily % carer understand death is imminent, goals of care are
palliative. <amily % carer are aware of the patientEs imminent death
and that they recognise measures are being taken to maintain
comfort. 8iscuss patient symptoms as re6uired. !"er pastoral care
and social work support. -nsure physical needs of those attending
the patient are accommodated. -nsure awareness of ward facilities,
visiting hours etc. rovide family with information brochures as
re6uired.
,oal /4" ?eview goal )) re location of dying
If decision is made to die at home commence E8ischarge ;ome
athwayE.
Shift +ate -ame 'print( 9ull signature +esignation &nitial
s
Section )a. To be completed by the Specialist Palliative $are Team after
patient review
,oal )). #ocation of dying has been
discussed
with the family 5 carer

Achieved

1ariance
lanned location of
dying
.roviding end of life care at home
for your family member# brochure
provided to carer if decision made
to discharge patient home

Achieved 1ariance
Section 1. To be commenced when it is decided that patient is going home to die
Objective
This section has been developed to guide the multidisciplinary care of stroke patients who are palliative and who are to be
discharged home to die.
It should be followed when the patient or family % carer have elected for the patient to die at home.
It should not be commenced unless the multidisciplinary team have agreed that the patient is dying, and the team,
patient and family % carers support the patient going home to die.
4radma label
This is a multidisciplinary plan of care. -ach discipline should initial after the intervention has been attended to and
record their full details in the name register at the end of the section.
8ischarge home pathway
commenced G 8ate Time
roposed date of
discharge
,oal /6" -on.essential medications are discontinued and post discharge medications
are prescribed for common symptoms which may arise
&nitial
5 +ate
7urrent medications assessed and non essential medication
discontinued Achieved

1ariance
arenteral route of medication delivery prescribed /for those not able to
swallow oral medication Achieved

1ariance
)yringe driver commenced if
appropriate 8ate commenced Time commenced
&N subcutaneous comfort medications written up and prescribed as take
home medication ensuring ade6uate supply until review by F /see sheets
at the back of care path for guidance0 Achieved

1ariance
ain Agitation )ei5ure activity
Nausea and
vomiting
&espiratory Tract )ecretions 4reathlessness 7onstipation
7omfort medications ordered and dispensed or pharmacy
script provided Achieved

1ariance
harmacy alerted to discharge and need for rapid supply of
discharge medication Achieved

1ariance
If patient is on a syringe driver ensure it is re+lled =ust
prior to discharge Achieved

1ariance
,oal /7" &nterventions re@uired for discharge to the community have been completed
&eferral made to 7ommunity alliative 7are via
)coTT tool Achieved

1ariance
7ommunity alliative 7are alerted to patient discharge and need for
early assessment Achieved

1ariance
ost Acute 7are referral completed for
community services Achieved

1ariance
-6uipment re6uirements assessed and ordered by the
!ccupational Therapist Achieved

1ariance
-6uipment delivered to discharge residence and in place
ready for use Achieved

1ariance
7ommunity nursing service informed of the source of all e6uipment items
loaned to patient Achieved

1ariance
7arer%family are provided with a summary outlining source and relevant
contacts for e6uipment Achieved

1ariance
7arer Training 7hecklist completed and family%carer have received training in all
relevant areas of care Achieved

1ariance
,oal /8" The family5carer understand and are prepared for patient
to be discharged home for end of life care and are aware death is
imminent

Achieved

1ariance
<amily%other aware of planned discharge
date%time Achieved

1ariance
Name of primary
carer &elationship Tel no.
8ischarge
address
<amily % carer aware of how community nursing services will
contact them Achieved

1ariance
<amily%carer informed of ward contact number for assistance prior to 7ommunity
alliative 7are visit Achieved

1ariance
,oal 1:" ?elevant correspondence completed ready for patient discharge and in accordance
with 'insert hospital( procedure
atientEs F is aware and supportive of
discharge home Achieved

1ariance
Hritten discharge plan%summary completed and provided to family%carer
prior to discharge Achieved

1ariance
7opy of discharge plan%summary sent to F and relevant
community services Achieved

1ariance
7opy of discharge plan +led in patients
medical record Achieved

1ariance
<amily%carer provided with information regarding referrals and appointments which
have been organised Achieved

1ariance
,oal 1)" Transport is arranged in preparation for patient discharge
Ambulance booked for Achieved
transport 1ariance
Ambulance sta" alerted that patient is Not for
&esuscitation and provided with a copy of the
9imitations of Treatment form Achieved

1ariance
&f you have charted A;arianceA against any goal so far, please complete variance in patient history
Shift +ate -ame 'print( 9ull signature +esignation &nitials
Section 2. ;eriBcation of death"
8ate of
death Time of death
&elative or carer present at time
of death >es No
If not present has a relative or carer
been noti+ed >es No
Nam
e
&elationsh
ip
Is this likely to be a
coroner#s case >es No
$are after death
,oal 1/" Procedure for laying out followed according to 'insert hospital(
procedure
'insert procedure number(

Achieved

1ariance
<amily consulted about speci+c religious % cultural % spiritual needs
All =ewellery should be removed from the body and lodged with security. 7lothing % valuables belonging to the patient
can be collected from the security ofcer. The nurse in charge, following proof of identi+cation, may issue personal
e"ects from the ward and this should be noted in the :edical &ecord /insert hospital procedure number0.
In 7oronial in6uiries all therapeutic, surgical and resuscitative e6uipment either inserted or attached to the body must
remain in situ
,oal 11" 9amily 5 carer are aware of the procedures following death and
are provided with appropriate information

Achieved

1ariance
4ereaved family % visitors allowed privacy to view
the body

Achieved

1ariance
Ne't(of(kin advised to contact a funeral director of their choice

Achieved

1ariance
roperty packed for
collection

Achieved

1ariance
:edical certi+cate provided for family members if
appropriate

Achieved

1ariance
<amily given information about procedures
following death2 coroners, post mortem, organ
donation as re6uired

Achieved

1ariance
Information booklet IHhen someone diesJ and
information lea3et on bereavement and local
support services given to family

Achieved

1ariance
,oal 12" The primary health team and ,P are contacted regarding
patient0s death

Achieved

1ariance
/Insert hospital name0 procedure followed regarding the recording of patient#s death /insert procedure number0
&f you have charted a ;ariance please complete the reason for variance in the patient medical record
<ealth
Professional
Signatu
re
+esignati
on +ate
-am
e
4radma label
This project is an initiative of the Victorian Department of Health (formerly Department
of Human Services) and funded by the Australian Government, Department of Health and
Aein, under the !ational "alliative #are "roram
Treatment protocols
). Pain treatment protocol

,. After ,@ hours
review medication. If
three or more doses
re6uired or
ine"ective within ,@
hours then consider
medical review and
syringe driver.
,. After ,@ hours
review medication. If
three or more doses
re6uired or
ine"ective within ,@
hours then consider
medical review and
syringe driver.
-O CDS -O CDS
Assess pain
Patient is in pain Patient0s pain is controlled
Is patient already taking oral morphineK Is patient already taking oral morphineK
*. 7ontact the
alliative 7are
Team
*. :orphine ,.L(L
mg G Lmg s%c prn
*. To convert a
patient from oral
morphine to a ,@
hour s%c infusion of
morphine, divide the
total daily dose of
morphine by B. -.g.,
:) 7ontin B?mg bd
orally M morphine ,?
mg via s%c driver over
,@ hours.
*. :orphine ,.Lmg G
Lmg s%c prn
,. rescribe prn dose
of morphine which
should be *%N of ,@
hour dose in driver.
-.g. :orphine B? mg
via driver will re6uire
L mg :orphine s%c
prn.
Supporting information
To convert from other opioids contact the alliative 7are Team for further advice as needed.
If symptoms persist contact the alliative 7are Team.
Anticipatory prescribing in this manner will ensure that in the last hours%days of life there is no delay in responding to
a symptom if it occurs.
/. -ausea and vomiting treatment protocol
1. ?espiratory tract secretions treatment protocol
-ausea5vomiting present -ausea5vomiting absent
Assess nausea and vomiting
*. :etoclopromide *?mg s%c bolus
in=ection @ hourly prn
*. :etoclopromide *?mgs s%c @
hourly prn
,. After ,@ hours review symptom. If
two or more prn doses given, then
consider medical review and use of a
syringe driver
B. :etoclopromide @?(N? mgs s%c via
syringe driver over ,@ hours
Supportive information
If symptoms persist contact the alliative 7are Team.
Anticipatory prescribing in this manner will ensure that in the last hours%days of life there is no delay in responding to
a symptom if it occurs.
Present Absent
Assess respiratory tract secretions
*. ;yoscine ;ydrobromide ?.@mg s%c
bolus in=ection. 7onsider syringe driver
*.,mg over ,@ hours
*. ;yoscine ;ydrobromide ?.@mg s%c
prn
,. 7ontinue to give prn dosage
accordingly
B. Increase total ,@ hour dose to
,.@mg after ,@ hours if symptoms persist
Supportive information
If symptoms persist contact the alliative 7are Team.
Flycopyrronium ?.@mg s%c prn may be used as an alternative.
Anticipatory prescribing in this manner will ensure that in the last hours%days of life there is no delay responding to a
2. +yspnoea treatment protocol
3. Terminal restlessness and agitation treatment protocol
Supportive information
If the patient is breathless and an'ious consider mida5olam stat ,.Lmg s%c prn.
If symptoms persist contact the alliative 7are Team.
Anticipatory prescribing in this manner will ensure that in the last hours%days of life there is no delay responding to a
symptom if it occurs.
Assess dyspnoea
+yspnoea present +yspnoea absent
Is patient already taking oral morphine for
breathlessnessK
:orphine ,.L G Lmg s%c prn
*. 7onvert to s%c
morphine and give @
hourly or via a
syringe driver G for
further advice and
support liaise with
the alliative 7are
Team
*. :orphine ,.Lmg G Lmg
s%c prn
-O CDS
,. After ,@ hrs
review medication, if
three of more doses
re6uired prn then
consider a syringe driver
at L(*? mg%,@ hrs over
,@ hrs
Supportive information
If symptoms persist contact the alliative 7are Team.
Anticipatory prescribing in this manner will ensure that in the last hours%days of life there is no delay responding to a
symptom if it occurs.
?estlessness 5agitation present ?estlessness 5agitation absent
Assess restlessness and agitation
*. :ida5olam ,.L G L mg s%c prn *. :ida5olam ,.L ( L mgs s%c prn
,. After ,@ hours review medication.
If three or more doses re6uired or
ine"ective within ,@ hours, then consider
medical review and syringe driver
B. :ida5olam via syringe driver L(*?
mgs over ,@%,@
,. If three of more doses re6uired
prn, consider the use of a syringe driver
over ,@ hrs