Advance care planning and syringe drivers in end-of-life care

• End-of-life care is a particular type of palliative care providing support and symptom control for those people thought to be in the last year of their life, although unpredictable disease trajectories can mean some people might only receive end-of-life care in their last weeks, days or hours
• Advance care plans allow the patient to state their preferred place of care and the future treatments they would wish to have or avoid
• A syringe driver—which allows drugs to be delivered subcutaneously at a constant controlled rate—is useful for symptom control when oral administration is not possible or effective, and repeated injections would be inappropriate or impractical

Palliative and end-of-life care is an important aspect of nursing. Around 500 000 people die in England every year (Dying Matters, 2020). The main causes of death are stroke and heart failure; however, one in four people in the UK will die of cancer (Office for National Statistics, ONS, 2020). As a result of an increasing and ageing population, a significant proportion of older adults will be living with comorbidity and therefore an increase in deaths due to comorbidity and frailty will likely pertain as a leading course of mortality in the coming years (National Institute for Health and Care Excellence, NICE, 2016). In response to this, nurses need to be managing and delivering services that can identify and care for people who require palliative care and are likely to be approaching the end of their lives (NICE, 2019).

Palliative and end-of-life care

Palliative care is treatment, care and support

Advance care plans

Advance care planning permits the patient to state their preferred place of care and what future treatments they would accept, particularly if their mental capacity is altered towards the end of life or they are unable to make decisions for themselves (Hamilton, 2017). Such decisions could mean that the patient will allow for active treatment at home such as for infection, emesis, or pain control, but would not want to attend hospital. These conditions can be managed via a number of administration routes at home. For example, if a patient needs medications normally administered orally, but this is problematic as a result of pathophysiological changes, these medicines can be delivered in the home subcutaneously either by injection for breakthrough relief of symptoms or continuously over 24 hours via a pump/syringe driver (Thomas and Barclay, 2015).

In some cases, where there is a palliative medical emergency that cannot

Setting up a syringe driver

• Syringe driver
• Luer lock syringes—manufacturers recommend the size of the syringe that should be used with their devices. Syringe drivers are calibrated in ml per hour. It is important to establish the final volume required in the syringe before choosing the size
• Drug label
• Butterfly needle or infusion set cannula
• Transparent surgical dressing
• Syringe driver case and battery
• Subcutaneous infusion set
• Water for injection or normal saline
• Medicines
• Sharps box
• Prescription and monitoring chart
• Non-sterile gloves
• Skin cleansing agent

Procedure

1. Explain the rationale for setting up the syringe driver and the procedure to the patient and relatives
2. Obtain consent
3. Wash hands
4. Check patient name and NHS number
5. Ask the patient if they have any known allergies
6. Check the battery for the syringe driver. If the battery is below 40% at the start of the infusion discard and use a new battery
7. Set rate—this is the rate at which the syringe plunger will be moved forward by the motor in ml/hour. Special attention should be paid to the rate if the machine has returned from servicing
8. Test the start button—this must be tested before administering the infusion. Press the start/test button and hold it down. Releasing the button starts the syringe driver. If the alarm does not sound the system is not safe to use (O'Brien, 2012)
9. Establish the final volume required in the syringe. It is considered good practice

Conclusion

Palliative and end-of-life care are an essential part of nursing care. With more people choosing to die at home it is important that nurses are competent in managing this process. End-of-life care should always be patient-centred and include advance care planning when considering treatment. Syringe drivers are useful when the oral route of administration is not possible or absorption of medication is not optimal. It is important that discussions about medication management occur throughout the dying process and are tailored to meet individual needs.