BTEC Level 3 Award in Awareness of working in End of Life Care

(EOLC)
Unit 3: Understand how to support individuals during the last days of life
Unit reference number: J/503/8137
QCF level: 3
Credit value: 3
Guided learning hours: 33
Unit aim
The aim of unit is to support learners in developing the knowledge and understanding
needed to be able to provide support for individuals and others in end of life situations.

Unit introduction
This unit introduces learners to the current approaches to end of life care. Learners will
examine the impact of national and local drivers on current approaches, and evaluate a
range of tools that can support workers in end of life situations.
Learners will consider models of grief and loss, and how they can be used to support
individuals as they face death. Learners will gain an understanding of the factors that may
affect communication in end of life situations, and examine ways of providing support to
individuals.
Learners will investigate the various symptoms that individuals experience, and Investigate
the different techniques used to relieve these symptoms.

Assessment guidance
This unit must be assessed in accordance with Skills for Care and Development's
QCF Assessment Principles.

Essential resources
There are no special resources needed for this unit.
Workbook appendices at back of workbook:
- Appendix1: Unit learning outcomes, assessment criteria and unit amplification

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Workbook: Understand how to support individuals during the last days of life
Unit Reference number: J/503/8137
This Workbook is designed to supplement the learning from the face-to-face taught
sessions, helping to link classroom learning to practice & to support learning in the
workplace. This Level 3 Unit builds on Unit EOL A/503/8085 and Y/503/8689. When you
are working through the activities in this Workbook please do remember that you will need to
be able to show evidence that you have achieved the Learning Outcome for each section
and you should aim to have more than one piece of evidence for each Learning Outcome.
There are a range of activities in this Workbook:
1. Those that involve looking at policy or theory & applying them to your workplace.
2. E-learning activities.
3. Reflective accounts or scenarios where you write about the care you have given to a
service user.
When you are writing about the care you have given to a service user please use I when
describing what you did: for example when writing about a time you supported a service user
when they had lost a close family member or a friend.
When I was helping Mr P to have his bath he started talking to me about another service
user Mrs. J, who had been transferred to hospital and had died there. He said that he
hoped he would not have to go back to hospital. As he was talking openly about this I asked
him what he would like to happen if he became less well? Mr P said that he would really like
to stay in here in the care home as he knew all the staff. I asked him if he had talked to
anyone else about this or had written it down. Mr P said he had not and was only thinking
about it because of Mrs J. I asked him if he would like to talk about this more after his bath,
he said yes he would.
If you are asked to write a reflection but do not have anything to reflect on as this is
your first experience with End of Life Care, please write a 'candidate statement' this
means writing 'I would' in place of 'I was'
You may like to share some of the information you gain from this Workbook with colleagues
or to create a resource file for your workplace. Please feel free to telephone or email me if
you need any support or guidance as you work thorough these activities.
Good Luck!
Joy Baker
Course Lead (Health & Social Care) Apprenticeship and Workforce Development
Bracknell & Wokingham College
E-mail: joy.baker@bracknell.ac.uk. Tel: 01344 766683
Liz Rankin. End of Life Care Facilitator
Berkshire Healthcare NHS Foundation Trust (BHFT)
E-mail: liz.rankin@berkshire.nhs.uk Tel: 07789504568

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Understand how to support individuals during the last days of life

Unit Reference number: J/503/8137
Planning Ahead
1.2 Define the circumstances when life-prolonging treatment can be stopped or withheld
1.3 Analyse the importance of any Advance Care Plan in the last days of life
In the Unit EOL A/503/8085 you considered the principles of Advance Care Planning and
what a service user needs to understand before writing their own Advance Care Plan (ACP)
while in Unit Y/503/8689 you were given the opportunity to consider how useful Advance
Care Plans are in practice. Refer back to this work if helpful.
There are times when life-prolonging treatment may not be appropriate; the latter are
treatments or procedures with the potential of postponing someones death (BMA 2007). In
some circumstances a service user may choose to complete an Advance Decision to
Refuse Treatment (ADRT) where they refuse a specified future treatment. However, if
refusing a life-sustaining treatment the ADRT must be written, signed & witnessed. ADRTs
that are both valid and applicable under the requirements of the Mental Capacity Act will be
legally binding for everyone involved in the care of the individual.
(http://www.ncpc.org.uk/sites/default/files/ADRT%20books.pdf)
However, even where no ADRT exists the potential benefits of any treatment have to be
balanced against any potential harm; the likely success of that treatment must also be
considered. A service user with a lung disease such as Chronic Obstructive Pulmonary
Disease (COPD) may have had several admissions to hospital with infection, but each time
they are a little less well on discharge, not improving with the oral antibiotics. Eventually the
service user may become very frail & no longer able to swallow but is again admitted to
hospital for antibiotics, however this time the antibiotics can only be given intravenously
(directly into the blood).
Therefore, on this admission it may not be in their best interests to have antibiotics, their
condition may not improve and the transfer to hospital may have caused them distress or
discomfort. It might therefore be better at this time to withhold (or to stop) any further
antibiotics.

Task 1
Reflect on a service user/s you have cared for who were in the last days of their life.
- Describe why an advance care plan was/is important and helpful at this stage
- Explain how an ACP can impact on choices made, treatments given and the care
delivered in the service users last days of life.
- Consider how the service users care could be affected where an Advance Care Plan
was not in place?
- In the last days of life it is sometimes necessary to stop or with-hold life
prolonging treatments, describe which treatments could be stopped or with-held?

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An advanced care plan is very important and helpful because give us the tools and the
directions for how to manage at this stage the care in the patients best interest and explain
clear what are them needs and wishes, etc.,
An ACP has a high impact on all the choices to be made as treatment, care delivered, and
the people to contact and visit, religious needs, after death care, etc.,
The importance of ACP is higher when the persons mental capacity is reduced because
ACP became our principal tool beside family that together with care staff will make decisions
in base that the wishes and the best interest of patient will be respected.
At this point is easy to understand how difficult is to work without a ACP because everything
will be a guess, and the wishes or choices specially in people with mental capacity problem
will be very difficult to understand and to meet.
In the last days of life some treatments that prolonged the life and if is the wish of patient
could be stopped.
Medication to stop:
Ventilation
CRP
The rules to respect for any decisions are:
Do good
Beneficence

Do not harm
No modified

Autonomy

Justice

The Psychological impact of dying

The psychological impact of death and dying can influence an individuals thoughts,
feelings and behaviour. psychological disturbance affects a patients quality of life
and their ability to cope with a disease and the treatment it requires.. (Selmer,
2015)

2.1 Describe the possible psychological aspects of the dying phase for the individual and others
2.2 Explain the impact of the last days of life on the relationships between individuals and others

Task 2:
Reflect on a service user/s you cared for in the last days of their life and his/her family.
Describe the psychological difficulties that the individual and his/her family experienced
during the dying phase.
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S.D 97 years old suffer from Dementia, Epilepsy and Parkinson diseases
Reduced capacity of communication, bed bound high level of daily care, medication for Parkinson and
Epilepsy. Distress and difficulty to cope on regular pain killer, in our case due to difficulty to
communicate and medical condition the resident was not able to express him.
Usually in last days of their life a person experienced a large range of emotions and feelings such as:
fear, anger, diner, sadness, lost of relationship, dignity, embracement, body image disturbance, peace,
or can be still booked in unfinished business, strange relationship, argument with someone and try to
resolve the situation.
The family spent the last day with the resident and tried to offer psychological and emotional support
Others around them:
Can experience a large range of feelings and emotions sadness, hopeless, sense of immortality, angry,
change of role, difficulty to speak, inadequate conversation or behaviour, frustration, feel guilty, feel in
peace and understand that the life is this, make peace with that person if was some discordance in
them past, etc.

Explain the impact of the last days of life on the relationships between the dying person and
others.
In any relationship between a dying person and others the impact is very strong, it is the moment to
resolve the unfinished problems, to make peace, to forgive, to accept, to help and to offer unconditional,
to speak, the role are changed sometimes, try to hold, sensate time, difficulty to approach,
psychologically distress related to psychically pain, nervozism, tiredness, need specialist support,
feeling of helpless, etc.

Individualised End of Life Care (EOLC) Plan

3.3 Describe how to use an Individualised End of Life Care Plan according to agreed ways of
working

o
o
o

In the Unit EOL Y/503/8689 (Task 1) you were asked to describe the main concerns in
relation to the Liverpool Care Pathway (LCP). A brief discussion took place during the
teaching session of the actions taken to address concerns raised:
- An independent review of the LCP took place under the chairmanship of Baroness
Julia Neuberger & a report was published on 15th July 2013: More Care, Less
Pathway: A Review of the Liverpool Care Pathway
The Liverpool Care Pathway was to be withdrawn by June 2014
As a result of this the Leadership Alliance for the Care of Dying People was formed and it
produced: One Chance to Get It Right (2014); in relation to the care of the dying patient
and their families this made :
34 recommendations
Identified 5 Priorities of Care (see Table 1) (www.nhsiq.nhs.uk/endoflifecare)
Table 1: 5 Priorities of Care
1 Recognise: The possibility that a person may die within the next few days or hours is
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2
3
4
5

recognised and communicated clearly, decisions made and actions taken in accordance
with the persons needs and wishes and these are regularly reviewed and decisions revised
accordingly.
Always consider reversible causes, e.g. infection, dehydration, hypercalcaemia etc.
Communication: Sensitive communication takes place between staff and the dying person
and those identified as important to them.
Involve: The dying person and those identified as important to them are involved in
decisions about treatment and care to the extent that the dying person wants.
Support: The needs of families and others identified as important to the dying person are
actively explored, respected and met as far as possible
Plan & do: An individual plan of care which includes food and drink, symptom control and
psychological, social and spiritual support is agreed, co-ordinated and delivered with
compassion.

Task 3:
Take time to read the Berkshire Healthcare NHS Foundation Trust (BHFT)
Individualised Care Plan for the Dying Patient.
- Completed document available: as Handout
You have been given a completed Individualised Care Plan for Michael Mouse,
a dying patient you have been asked to visit at home.
Read the full care plan, in particular the problems identified on pages 5- 11.
In what way will an Individualised Care Plan for the dying patient help you to
care for Michael and other patients? Answer below.
An individualised Care Plan help us to understand Michel or others patients needs, wishes,
wills, believes and in base of this to provide the best care and support.
When we do a ICP need to take in consideration
Physical needs intake, elimination and cleaning needs,
Medical needs (management of pain release medication)
Spiritual needs, bereavement support
Maintain Dignity and Privacy

Below are the problems identified when you visited Michael at home
Michael had chest pain overnight and is finding it difficult to swallow his pain liquid.
Michaels family (wife, son & daughter) are very upset as Michael was agitated and
unable to settle last night
Michael is having difficulties swallowing & his mouth appears sore and his tongue is
furred and dry
Michael has been incontinent of urine
Write below what care you would give to Michael and his family and where you
would record this in Michaels Individualised care plan.

Continue assessment and monitoring of medical and physical condition

Continue monitoring of fluid/diet intake, elimination and cleaning needs that are giving
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according with the procedures and ICP.

Michel is on pain killer according with GP prescription. If in pain or the condition will
become worse GP must be informed and reviewed his medication.
Physiological support for his family, discuss with them what possibility there are, take in
consideration possibility to have a trained assistance or to be transferred (as his wish) in
a hospice.

Outline a range of ways in which Michaels needs may change in the last days of
life. (Consider: Physical, skin integrity, mouth care, medication changes,
psychological, social, emotional, personal care, fluids/nutrition, faith /spirituality
/culture. Others)
Michel needs will be monitored and assessed continually and care will be given in base to
his present needs.

Physical
Medication needs
Swallow
Mobility
Weight
Communication
Sleeping
Fatigue
Skin integrity
Incontinence needs

Psychological
Scared, fear, stress, anger, dinar, acceptance, communication, level of consciousness
Spiritual

Spiritual support
Place to be bared
Contact numbers
Reconciliation

Socially
Family near
Loneliness
Wish to visit the places important for him/her
Isolation
Place of death

Please identify 3 physical symptoms and 3 psychological symptoms & describe

a range of ways you have used to enhance an individuals wellbeing during the
last days of their life.
Physical symptoms : elimination issues, personal & cleaning needs, lost of blood, anaemia,
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intake/nutritional issues:

Breathless
Relaxation technique / Alternative therapy
Oxygen therapy / Inhalers/ nebuliser

Skin integrity
Check pressure area/ position change
Wound care/treatment
Elimination and cleaning needs regularly

Month care
Regularly cleaning and moisturising

Panic
Complementary therapy / relaxation techniques
Communication / Company of others
Flowers / cards

Fear
Communication, talk, listening, be present
Spiritual and psychological support
Alternative therapy

Withdrawn
Be present, family near, listen, communication, past experiences - father experience in
Michel case,

Describe the common signs of approaching death?

Fluid leaking, secretions

Blood results change
Skin colour changing
Breathing problems, noisy respiration
Circulation reduced, the blood temperature decrease
Elimination problems, retention, urine dark colour, bad smelling and condensed.

The importance of working in partnership with key people and key

information about the process following death
3.2 Explain the importance of working in partnership with key people to support the individuals
wellbeing during the last days of life
3.4 Describe key information about the process following death that should be made available to
appropriate people according to agreed ways of working
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In Unit EOL A/503/8085 you considered the range of support services & facilities available to
an individual & others, it is also important to be aware of which key people provide support
to dying people and their families and what information families might require about the
process following death.

Task 4:
Below identify which key people you work with when caring for dying patients, why it
is important to work with them and what your role is?

Title

Why it is important to work with this person and what is your role?

GP

Change medication or medical condition, control of symptoms, etc.

Hospital

If the patient request is to be cared in the hospital or the medical condition

request hospital care because cant be given in Care Home

Priest, psychologist

Spiritual and psychological support

Relatives, either in their own home or when visiting family members in the care
home often ask questions about the processes following death.
Identify the questions they might ask and how they could be answered?
There are a large range of questions that the family can have for example:
If is in pain? depend of situation but we explain that our main goal is to keep him
comfortable, free of pain and in connection with GP we monitored continue the resident and if
is necessary his medication for EOL is reviewed
If we know when will happening? we cant answer to this question but what we can do is to
ensure the resident is comfortable and receive the best care.
What to do before and after? we explain the procedures and give the contact numbers

Have you any literature that relatives might find useful at this time, if so please
describe briefly?
In our care home we have different kind of leaflet or informational support that we put at disposition of
residents or family. The management also has a very close relation with them and bring in attention
all the information or possibility so the family will be able to do the chose in base of them situation.

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Identifying death and care after death

1.4 Identify the signs that death has occurred

4.2 Explain the importance of being knowledgeable about an individuals wishes for their afterdeath care
4.3 Explain the importance of acting in ways that respect the individuals wishes immediately after
death

Step 6 of the End of Life Care Pathway (EOLC Strategy, 2008) addresses care
after death and recognises that EOLC does not end with the death of the service
user.

Task 5:
Recognising that someone has died is very important as it enables appropriate care and
support to be given to the service user and their loved ones. However, your role in relation to
recognising death will vary depending on your responsibility within the home/community.
List the signs which identify that someone has died

No breathing
No pulse,
Heartbeat stopped,
Dilated pupils,
Unresponsive

Describe your role within the home/community if you believe/know someone has died.

Indentify the death

Inform GP, out of hours doctors, inform family if not present
Discuss next steps with family
Call funeral directors

Task 6:
-

Explain why it is important to be knowledgeable about an individuals wishes for

their care after death. Answer the question by using examples; these could be
spiritual or religious needs or wishes about who was to be present with them when
they died.
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Why is it important to act in a way that respects the individuals wishes immediately
after death, it might help to answer the question by using examples?

It is important because everyone is different and sometimes they come from different religion
with different needs so is necessary to know what the wishes are and ensure them are
respected.
Our role as nurse in Care Home finished immediately after the death was indentified and the
funeral directors took the body.

4.1 Explain national guidelines, local policies and procedures relating to care after death
4.4 Describe agreed ways of working relating to prevention and control of infection when caring for and
transferring a deceased person

This unit will be completed by those working in care homes, the community and community
hospitals. Some organisations will have their own policies on how to care for the deceased
service user/patient/resident but for some there is limited contact with deceased service
users and their families at the time of death and afterwards and the organisations do not
currently have guidelines. Where organisations do have a policy/guidelines they should
reflect national guidelines. (Care after death. Guidance for staff responsible for care after
death: http://www.nursingtimes.net/download?ac=1301667)
.
Before completing this part of your workbook discuss your organisations policy and
procedures with your manager or other colleagues.

Task 7:
Write down what is included in the National Guidelines relating to care after death.
Usually in care home our responsibility as nurse finish immediately after the body was taken.
Of course the management and administration will be still in communication with the family and
other as CQC, GP, funeral directors, etc. depend of case.

Identify the main areas addressed by your organisations guidelines/policy relating to care
after death. However, if your organisation currently does not have guidelines, please list
the areas that you believe should be addressed to ensure the continuation of high quality
care after the service user has died.
Usually in care home our responsibility as nurse finish immediately after the body was taken.
Of course the management and administration will be still in communication with the family and
other as CQC, GP, funeral directors, etc. depend of case.

Now consider your organisations infection control policy. Describe agreed ways of
working in relation to prevention and control of infection when transferring a deceased
service user.
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Where your role does not involve transferring a deceased service user answer this
question in relation to moving or handling a service user following death.
The procedures in our Care Home in EOL case are:
After we indentify the death and the authority and family were informed usually we need to inform
funeral services agreed with the family and they will transfer the body.
If the patient suffers from a contagious disease we must follow the procedures for infection control.

Identifying when support is needed for others and yourself and

identifying available support mechanisms
Task 8:
Reflective Questions
1. Consider the family and friends of a service user whom you have supported
immediately after death and describe the ways in which you gave support to them. If
you have not had any direct experience of this, describe what you would do in this
situation.
Feel compassion, show high level of professionalism and to inform them continually
so the family will feel more confident and tranquil. To treat with respect, dignity and
professionalism to give the best care and support.
2. Take time to consider the impact of caring for service users at the end of life and
think about the impact or possible impact which this may have on your own feelings.
Please describe some of these feelings and emotions (remember some of these may
be positive feelings).
I have experimented a large range of feelings such as:
The feeling of immortality,
sadness,
try to enjoy the life because is so fragile,
grateful for the miracle named life,
compassion

3. Take time to identify possible support systems which help you to manage your
feelings in relation to an individuals death. For each source of support
identify specifically how this helps you.
Help me to read, to go in gym, cinema, theatre to go in trips, to be with my friends and
family, to enjoy every moment and feel happy, to go in nature, to dance and to do yoga, to
meditate.
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Appendix 1: Learning outcomes, assessment criteria and unit amplification

To pass this unit, the learner needs to demonstrate that they can meet all the learning outcomes for the unit. The assessment criteria

Assessment Criteria

Learning Outcome

Understand common features of

support during the last days of life

Describe the common signs of approaching death

1.
1
1.
2
1.
3
1.
4

Understand the impact of the last days

of life on the individual and others

2.
1
2.
2
2.
3

Know how to support individuals and

others during the last days of life

Eviden
ce
Locatio
n
Task 3

3.
1

Define the circumstances when life-prolonging treatment can

be stopped or withheld

Task 1

Analyse the importance of any Advance Care Plan in the last

days of life

Task 1

Identify the signs that death has occurred

Task 5

Describe the possible psychological aspects of the dying

phase for the individual and others

Task 2

Explain the impact of the last days of life on the

relationships between individuals and others

Task 2

Outline possible changing needs of the individual during the

last days of life

Task 3

Describe a range of ways to enhance an individuals

wellbeing during the last days of life

Task 3

Explain the importance of working in partnership with key

Task 4

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Date
Achieve
d

3.
2
3.
3

Describe how to use an Individualised End of Life Care Plan

according to agreed ways of working

Task 3

Describe key information about the process following death

that should be made available to appropriate people
according to agreed ways of working

Task 4

Explain national guidelines, local policies and procedures

relating to care after death

Task 7

Explain the importance of being knowledgeable about an

individuals wishes for their after-death care

Task 6

Explain the importance of acting in ways that respect the

individuals wishes immediately after death

Task 6

Describe agreed ways of working relating to prevention and

control of infection when caring for and transferring a
deceased person

Task 7

4.
4
4.
5

Describe ways to support others immediately following the

death of a close relative or friend

Task 8

Define possible impact of an individuals death on own

feelings

Task 8

3
3.
4

Understand the actions to be taken

following an individuals death.

4.
1

4.
2
4.
3

Know how to manage own feelings in

relation to an individuals dying or
death

people to support the individuals wellbeing during the last

days of life

5.
1

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5.
2

Identify available support systems to manage own feelings in

relation to an individuals death

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Task 8