17 - Palliative Care/Care of the Dying Patient

Question 1

What is Palliative Care vs EOLC?

Answer 1

Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months

Question 2

What are the biggest causes of death in the UK and where do most people die?

Answer 2

Hospital

Question 3

Why is being able to identify death as a possible outcome important?

Answer 3

Allow patients a comfortable death in a place of their choice and to allow those important to them to prepare accordingly

Clinicians should address reversible problems compromising quality of life while prioritising the patient’s wishes and comfort

Question 4

What are the issues with recognising when to convert to EOLC?

Answer 4

Question 5

What tool can we use to recognise when a patient is deteriorating and may be approaching EOL?

Answer 5

SPICT or Gold Standard Framework

Question 6

What are some general indicators of decline in palliative patients?

Answer 6

• Unplanned hospital admission(s).
• Performance status is poor or deteriorating
• Dependent on others for care (CFS is 7)
• Carer needs more help and support
• Significant weight loss
• Persistent symptoms despite optimal treatment

• A decision to reduce, stop or not have treatment

Question 7

What are some physiological changes you seen in the hours before death?

Answer 7

• Cheyne-Stokes respiratory pattern
• Shallow breathing
• Use of accessory muscles of respiration
• Respiratory secretions
• Skin colour changes
• Temperature changes at extremities
• Decreasing levels of consciousness- leading to coma
• Agitation/restlessness
• Decreased urine output/ incontinence
• Decreased/Absent oral intake
• Difficulty swallowing

Question 8

How can decisions regarding EOLC be made?

Answer 8

If patient has capacity

• Joint decision between doctor and patient, weighing up benefits and risks, see image

If patient does not have capacity

• If any LPA or Advance Directive to Refuse Treatment always consult these first
• Best interest decision using Advanced Care Plan, family input and MDT input if no capacity

‘If your Dad could talk what do you think he would think about this treatment?’

Question 9

Advanced Decisions to Refuse Treatment and LPA are legally binding. When are they valid?

Answer 9

When patient has LOST capacity

Question 10

What form commonly used is a type of Advanced Care plan?

Answer 10

ReSPECT form

Question 11

How would you handle this situation?

Answer 11

Question 12

What is the Principle of Double effect in palliative care?

Answer 12

Helps distinguish between euthanasia and withdrawing treatment

Question 13

Give an example of the principle of double effect in cancer care.

Answer 13

Question 14

What are the 5 priorities of care for a dying patient?

Answer 14

Question 15

What are some anticipatory medications prescribed in palliative care?

Answer 15

Question 16

How should eating and drinking be managed in EOLC?

Answer 16

• The patient should be supported to eat and drink if they wish to do so
• Discuss the risks of aspiration if a concern
• Relatives may get concerned not eating and drinking but this is normal

Question 17

What should you offer for hydration in EOLC?

Answer 17

• Good mouth care
• Assess daily re hydration status
• Discuss risks and benefits of CAH; may relieve symptoms secondary to dehydration, but may cause other problems

Question 18

How are the different types of diabetes managed in the last few days of life?

Answer 18

Question 19

What legal frameworks are used in palliative care decision making?

Answer 19

• Mental Capacity Act
• Advanced Decisions to Refuse Treatment
• Lasting Power of Attorney

Advanced Care Plan is NOT legally binding

Question 20

Apart from medical management of EOL symptoms, what other management can be done for these patients?

Answer 20

• Psychological, social and spiritual support to patients
• Supporting those close to the patient

Question 21

When making a best interest decision for a patient who has lost capacity and is EOL, what is this process called?

Answer 21

‘Overall benefit’

Question 22

If a patient does not have any close family or legal proxy to help support a best interest decision what can be done?

Answer 22

Appoint an Independent Mental Capacity Advocate (IMCA)

Question 23

What should you do before you tell family members about a patients prognosis?

Answer 23

That their family member consents to this information being shared if they still have capacity

If do not check this is breaching confidentiality

Question 24

If there is uncertainty about the overall benefit of a particular treatment what should be done?

Answer 24

Start the treatment so a clearer assessment can be made

Question 25

If a patients diagnosis is likely to lead to them losing capacity as time progresses, what things do you need them to consider when writing an advanced care plan?

Answer 25

• Wishes, preferences or fears in relation to their future treatment and care
• Feelings, beliefs or values that may be influencing the patient’s preferences and decisions
• Who would they like involved in their care e.g family, legal proxy
• Interventions which may be considered in an emergency e.g CPR
• Patient’s preferred place of care (and how this may affect treatment options available)
• Patient’s needs for religious, spiritual or other personal support
• Any organ donation?

Question 26

What is a more legal advanced care plan?

Answer 26

Advanced directive

Question 27

When making a ADRT, what criteria needs to be met?

Answer 27

• Patient was an adult when the decision was made
• Patient had capacity to make the decision at the time it was made
• Patient was not subject to undue influence in making the decision
• Patient made the decision on the basis of adequate information about the implications of their choice
• Patient has not appointed an attorney, since the decision was made