17 - Palliative Care/Care of the Dying Patient Flashcards
What is Palliative Care vs EOLC?
Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months
What are the biggest causes of death in the UK and where do most people die?
Hospital
Why is being able to identify death as a possible outcome important?
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
What are the issues with recognising when to convert to EOLC?
What tool can we use to recognise when a patient is deteriorating and may be approaching EOL?
SPICT or Gold Standard Framework
What are some general indicators of decline in palliative patients?
- 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
What are some physiological changes you seen in the hours before death?
- 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
How can decisions regarding EOLC be made?
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?’
Advanced Decisions to Refuse Treatment and LPA are legally binding. When are they valid?
When patient has LOST capacity
What form commonly used is a type of Advanced Care plan?
ReSPECT form
How would you handle this situation?
What is the Principle of Double effect in palliative care?
Helps distinguish between euthanasia and withdrawing treatment
Give an example of the principle of double effect in cancer care.
What are the 5 priorities of care for a dying patient?
What are some anticipatory medications prescribed in palliative care?
How should eating and drinking be managed in EOLC?
- 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
What should you offer for hydration in EOLC?
- 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
How are the different types of diabetes managed in the last few days of life?
What legal frameworks are used in palliative care decision making?
- Mental Capacity Act
- Advanced Decisions to Refuse Treatment
- Lasting Power of Attorney
Advanced Care Plan is NOT legally binding
Apart from medical management of EOL symptoms, what other management can be done for these patients?
- Psychological, social and spiritual support to patients
- Supporting those close to the patient
When making a best interest decision for a patient who has lost capacity and is EOL, what is this process called?
‘Overall benefit’
If a patient does not have any close family or legal proxy to help support a best interest decision what can be done?
Appoint an Independent Mental Capacity Advocate (IMCA)
What should you do before you tell family members about a patients prognosis?
That their family member consents to this information being shared if they still have capacity
If do not check this is breaching confidentiality
If there is uncertainty about the overall benefit of a particular treatment what should be done?
Start the treatment so a clearer assessment can be made
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?
- 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?
What is a more legal advanced care plan?
Advanced directive
When making a ADRT, what criteria needs to be met?
- 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
