Policy Number LCH-85 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name Subcutaneous Rehydration Guidelines Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1 Policy for the administration of subcutaneous hydration in the community 2017 Version 2 1
SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy Policy for the administration of subcutaneous hydration in the community 2017 Version 2 2
Title Guideline reference number Aim and purpose of guideline Author Type Policy for the Administration of Subcutaneous Hydration by Liverpool Community Health 85 To support the administration of subcutaneous rehydration in the Community Intravenous Therapy Team Palliative Care Team New Policy Reviewed Policy X Review date December 2019 Person/group accountable for review Community Intravenous Therapy Team Palliative Care Team Issue Date 19 th December 2017 Authorised by Clinical Standards Group December 2017 Equality Analysis Assessment Undertaken Yes x Evidence collated Yes x No No Policy for the administration of subcutaneous hydration in the community 2017 Version 2 3
Document Control Title Policy for the administration of Subcutaneous hydration by Liverpool Community Health Status Review guidelines- New policy Version 2 Date Issued December 2017 Review Date December 2019 Originator Chris McBride End of Life Operational Lead Alison Smith IVT Operational/Professional Lead Reviewer Reviewed by Victoria Ali Palliative Care Team Leader/Sara Caddick MMT/Debbie Doyle IV team Policy for the administration of subcutaneous hydration in the community 2017 Version 2 4
1.0 Purpose of Policy This policy purpose is to make Liverpool Community Health staff aware of: 1. Indications for administration of subcutaneous fluids for patients 2. Ethical and Medical considerations 3. The method of administration of subcutaneous fluids This policy has been developed to support Liverpool Community Health NHS Trust staff in decision making and administration of subcutaneous fluids in patients with a palliative diagnosis and is also supported by an associated standard operating procedure (SOP). The policy highlights the need for a collaborative approach when considering administration of subcutaneous fluids in the community. This policy also explores the complexity of the medical and ethical issues in the decision making process with the aim of improving nursing practice and patient outcomes. They should be read in conjunction with, and is based upon, the One Chance to get it Right document (2015), The National Council for Palliative Care: Changing Gear Guidelines for Managing the Last Days of Life in Adults (Nov 2006), NICE Guidance: Care of dying adults in the last days of life (2015) and Cheshire & Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines for the use of hydration in the dying patient (2017) This policy is designed to ensure that all staff working for, or on behalf of the trust, provides an optimum level of service delivery to this specific patient population. The advice and guidance contained are research based and have been agreed by a multi professional group. 2.0 Scope of policy Liverpool Community Health NHS Trust has developed this policy in order to fulfil the requirements of patients/service users receiving care from District Nurses employed by Liverpool Community Health NHS Trust. 3.0 Decision-making Reduced oral intake is a common sign of deteriorating clinical condition, is common in the last few days of life and is part of the normal dying process. Oral fluids are part of basic patient care and as such should be encouraged whenever possible. In deciding whether or not to use subcutaneous hydration for a dying patient the health care professionals have to assess the benefits the patient is likely to gain against the burden it imposes on the patient. There is a general lack of robust evidence regarding the benefits and burdens of clinically assisted hydration at the end of life and as such decision should be individualised to each patient. There is also no strong evidence whether sub-cutaneous rehydration will affect symptom control at end of life (NWCSN standards and guidelines 2017, Forbat et al 2017). The assessment can help guide a patient and family s choice of the options available to the patient. The patient must always be involved in the assessment of the benefits and burdens of any treatment when this is possible. Inclusion of the family and carers is important in any
discussion, although making choices may provoke anxiety and be distressing for family members. Families need to have a clear understanding of what the subcutaneous fluids are being used for. Decision-making must be with the multi-professional team, patient and relatives where appropriate and should be clearly documented in case notes. Cheshire and Merseyside Palliative and End of Life Care Strategic Clinical Network Standards and Guidelines (2017) have reviewed the most recent evidence and produced general principles, guidelines and standards regarding artificial hydration for people who are terminally ill. In the community setting indications should be symptom led, both physical and psychological, and it will be based on palliation of symptoms rather than rectifying biochemical imbalance. Likewise whether rehydration should be continued, an assessment should be made as to whether the hydration regime is assisting in relieving the symptoms. This assessment should be undertaken on a daily basis. Subcutaneous rehydration is not adequate to correct severe dehydration or electrolyte imbalance; if this is appropriate these patients will require assessment and may need inpatient services for assessment and treatment. Indications for administration of subcutaneous fluids for patients with palliative diagnosis/end of life Dehydration can commonly occur in older people and those approaching the end of life, both at home and institutional settings. Acute problems such as mild infections, vomiting, diarrhoea, and temporary confusion due to changes in medication could all precipitate dehydration because an adequate fluid intake cannot be maintained. Oral fluid intake will also naturally reduce as a person approaches the end of their life and this must be taken into account when assessing where artficial hydration is appropriate. Sub-cutaneous hydration may be appropriate for those with mild dehydration or to manage the symptoms of dehydration and thirst in palliative and end of life care. Dehydration and reduced oral intake can be problematic, the reasons for this are often multifactorial, and is associated with many symptoms, one of the most troublesome being thirst. The provision of oral fluids and oral hygiene forms part of basic care and should not be withdrawn or withheld. This is supported by the SOP for the use of oral swabs with foam head for mouth care (see reference list). However it is ambiguous whether these fluid deficits adversely affect the patient s quality of life. Contradictions for Subcutaneous Hydration Severe dehydration Cardiac Failure Pre-Renal or Renal Failure Low platelet or coagulation disorders
Existing fluid overload Marked oedema Hypercalcaemia can be a cause of dehydration and is classed is an ionised plasma calcium concentration above the upper limit of normal. Diagnosis is based on a high level of clinical suspicion and confirmed by appropriate blood tests. A full medical assessment is needed to ensure that patients who require fluid replacements for correction of specific problems are identified. Dependent upon the overall clinical picture treatment with Bisphosphonates and IV hydration may be more appropriate than less aggressive subcutaneous management, see Bisphosphonates policy for further guidance. Consider referral to IV team for treatment of hypercalcaemia with IV Bisphosphonates and refer to the specialist palliative care team for future advice. Families and carers need to be informed that this treatment will be reviewed on a daily basis by a health care professional: that this form of treatment is largely temporary but there will be exceptions to this based on a MDT decision. If there is no improvement after 72 hours or treatment is not tolerated then it would be inappropriate to continue. The family will be informed of how to monitor the site by observing the infusion and site integrity once it has been commenced and if there are any problems to contact District Nurse. 4.0 Ethical and Medical Considerations The assessment should be individualised, involve members of the multidisciplinary team, and include the views of the family and carers. These patients will require referral to the specialist palliative care team for review and ensuring that the decision for treatment must outweigh the disadvantages of the proposed treatment taking into account the ethical and medical considerations. Practitioners should always take into consideration the NMC Code: professional standards of practice and behaviours for nurse and midwives (2015) with regards to clinical judgement and professional accountability. Artificial hydration such as intravenous or sub-cutaneous fluids is classed as medical treatment in common law. The primary goal of any treatment in terminal care should be the comfort of the patient and the ethical basis of the clinical decision is the assessment of the benefit vs burden of treatment. It is unethical to have a blanket policy on clinically assisted hydration and cases should be reviewed individually and must take into consideration any advanced decisions made by patients (refer to Mental Capacity Act 2005). The issues raised in deciding whether or not to use subcutaneous hydration are sensitive for all concerned, the patient, family and healthcare professional. The patient and the family will need to be supported with any decision made by the multidisciplinary team. For these reasons it is anticipated that a member of the specialist palliative care team would be involved in the decision and support of the family. Where the patient is felt to be in the last few days of life the End of Life Care Plan would be in use and symptoms managed accordingly. 5.0 The method of administration of subcutaneous fluids
See accompanying SOP for the administration of sub-cutaneous fluids Site of Infusion: To rotate sites to minimize tissue damage Abdomen Chest Lateral aspect of upper arm or thigh Do not use on: skin Lymphoedematous and oedematous tissue or recently irradiated It is recommenced to infusion 1 Litre of 0.9% Sodium Chloride over a 24 hour period. There is no evidence that supplementation of fluids with potassium is of benefit for patients in the last hours or days of life (NWCSN standards and guidelines 2017). Potassium should not to be administered subcutaneously and as such only 0.9% NaCl is for use via this route. There is also no evidence to support the reassessment of blood test in this clinical situation (NWCSN standards and guidelines 2017). The manufacturer of fluids for infusion applied for and granted the specific Product License which is for the purpose of Intravenous Infusion only. Therefore the use of these sterile fluids for the purpose of Subcutaneous Infusion is unlicensed procedure. As such the prescriber must take full responsibility for the efficacy of the medicine (infusion fluid) and for any adverse effects resulting from its use. 6.0 Training and Education The NMC state that in order to revalidate their professional registration that nurses maintain their competence via Continued Professional Development. Training will be provided in administration of Subcutaneous Fluids as part of the Intravenous Therapy Theory Training. Training in communication skills is essential to ensure any conversations that take place at end of life are handled sensitively and empathetically. Training in intermediate communications skills are also advocated for staff caring for those at end of life. 7.0 Patient Monitoring At each visit check the infusion rate and also check infusion site for and document VIP score of infusion site within the patient s clinical record. Monitor for: Redness Pain /tenderness Inflammation Any signs of oedema (pulmonary and peripheral) Leakage at site
Abscess formation Bleeding/bruising Inform GP immediately if present and stop infusion, complete clinical observations if this is suspected and escalate as per the observations policy The giving set should be changed each time the fluids are administered The needle safe butterfly and giving set should be changed every 72 hours and recorded (RCN Standards for Infusion Therapy (2016) The needle safe cannula or needle safe butterfly can be capped off in between with a sterile bung or bionector if fluids not being administered continuously. Infection control policies regarding hand washing must be followed at all times; the administration system must only be accessed by healthcare workers who have washed their hands as per policy and are wearing the appropriate PPE. Patient and carers must also be taught appropriate hand hygiene and encouraged not to touch the administration system. The patient should be monitored daily. 8.0 Definitions Community refers to the patient s own home and also includes residential and nursing homes. Subcutaneous (SC) refers to administration of fluids into the subcutaneous tissue in order to achieve fluid maintenances or replacement in dehydrated patients. Butterfly refers to the short needle safe peripheral device through which the fluids will be given directly into subcutaneous tissue. TPR + BP Temperature, Pulse, Respiration and Blood Pressure relating to clinical condition GP- General Practitioner
9.0 References Cheshire and Merseyside Palliative an End of Life Care Strategic Clinical Network Standards and Guidelines (2017) Guidelines for the use of hydration in the dying patient. Access electronically at https://www.nwcscnsenate.nhs.uk/strategic-clinical-network/ournetworks/palliative-and-end-life-care/auditgroup/clinical_standards_and_guidelines/ Document references available online Forbat, L et al (2017) How and why are subcutaneous fluids administered in an advanced illness population: a systemic review. 26 (9) 1204-1216 Leadership Alliance for the Care of Dying People (2014) One Chance To Get It Right: Improving peoples experience of care in the last few days and hours of life. Access electronically at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/3231 88/One_chance_to_get_it_right.pdf Moriarty D & Hudson E (2001) Hypodermocylsis for rehydration in the community. Journal of Community Nursing. Vol 6 (9). National Council for Palliative Care Services and the Association of Palliative Medicine of Great Britain and Ireland (2007). Artificial nutrition and hydration: guidance in end of life care for adults. London: NCHSPCS. National Institute for Clinical Excellence (2015) Care of dying adults in the last days of life. Access electronically at https://www.nice.org.uk/guidance/ng31 Royal College of Nursing (2016) Standards for infusion therapy (4 th Edition), London: RCN
Equality Analysis Completed November 2017 Held by author Audit Tool: An audit based on Duthie standards will be conducted in 2018/19 measuring against the following criteria: How often subcutaneous fluids are required in a sample three month period How many patients gained benefit from subcutaneous fluids and any complications that arose