Use of the AMBER care bundle and Individualized Dying Person's Care Plan in hospitalised stroke patients.

Introduction 

The AMBER care bundle is a tool supporting recognition and communication for patients with uncertain recovery. Patients may recover or be recognised as dying. Its focus is enabling patients and families to consider future wishes. The aim is to make sure that patients and their carers are involved as much as they want in shared decision making. Alongside AMBER, the Individualized Dying Person's Care Plan (IDPCP) is used in stroke care. We evaluated these tools, assessing initiation timing and if anticipatory prescribing tracked formal dying recognition.

Methods 

Retrospective review of 134 stroke patients who died on a Northampton General Hospital stroke unit (2023–2024). Demographics, tool use, timing, anticipatory prescribing, and intervention withdrawal were extracted from clinical records.

Results 

Median age was 81; 72.4% had ischaemic stroke. AMBER was used in 71.6% and the IDPCP in 82.1%. Median admission to AMBER was 3.5 days. Patients reaching the IDPCP directly did so faster (median 3.1 days) than those passing through AMBER (10.0 days; p=0.0003), with a median AMBER-to-IDPCP interval of 5.0 days. Anticipatory prescribing was near-universal upon reaching the IDPCP (direct: 100%; via AMBER: 97.6%), but occurred in only 7.1% on AMBER alone (p=0.024). Overall, 81.3% received anticipatory medications. Among IDPCP patients, intervention withdrawal ranged 79.6–97.1%, though oxygen was withdrawn in only 46.6% of dying patients. Nasogastric tubes were removed before death in 94.4% of patients in whom they had been sited. Concurrent infection was present in 70.9% of patients, and 44.8% of deaths were attributed to a combination of stroke and infection.

Conclusions 

Anticipatory prescribing was determined almost entirely by formal recognition of dying via the IDPCP. AMBER necessitates daily review where anticipatory medication is considered if indicated. However, blanket subcutaneous prescribing without rationale in AMBER patients risks inappropriate administration. AMBER patients might benefit from being referred to specialist palliative care for symptom management support. Upon IDPCP initiation, intervention withdrawal was prompt, though oxygen withdrawal lagged behind other measures.