7. End of life care Flashcards
Most common causes of death in UK today
Cancer and IHD
- Since 1995, cancer has outstripped IHD
- In the young, accidents account for 38% of deaths in boys and 23% of deaths in girls
- In men aged 15-34, suicide is the main cause
Describe terminal care
Terminal care is the last phase of care when a patient’s condition is deteriorating and death is close
It is often misleadingly only associated with cancer
Palliative care is a more helpful term for the management of conditons until the terminal phase is reached
Define palliative care
Paliative care encompasses end of life care r_egardless of cause of illness,_ and doctors are encouraged to consider which patients would benefit from palliative planning and treatment from early on in their illenss - allowing discussions of pts wishes with them and to care for them in a way which suits them best.
Not always a clear distinction fo what is curative and what is not.
Palliative care emphasises QoL - most provided in primary care and GPs act as companions on a journey
WHO definition for palliative care
The World Health Organisation state that:
“Palliative care improves the quality of life of patients and families who face life- threatening illness, by providing pain and symptom relief, spiritual and psychosocial support… from diagnosis to the end of life and bereavement”
WHO principles for palliative care
- Provides relief from pain and other distressing symptoms
- Affirms life and regards dying as a normal process
- Intends neither to hasten nor postpone death
- Integrates the psychological and spiritual aspects of patient care
- Offers a support system to help patients live as actively as possible until death
- Offers a support system to help the family cope during the patients illness and in their own bereavement.
- Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated.
How do we recognise that someone is in need of palliative care or that someone is dying?
- Often the MDT team will tell you
- The patient themselves or their family might tell you
- Clinical skill and experience – knowledge of the patient over time
- There are some useful tools to help…
- SPICT
- PPS
- Disease trajectories
Name some important aspects of palliative care
- Recognition that someone is dying and communicating that:
- patient
- family
- MDT
- OOHs
- Specialist
- Taking time to find out the wishes and concerns of the patient and family
- Pre-empting problems rather than reacting to them - e.g. symptom control, aids in the home etc.
What is SPICT (Supportive and Palliative Care Indicators Tool)
- Guide for doctors to consider their patients who have a life-limiting diagnosis, or a worsening chronic condition, and highlight if they are at a stage where supportive and palliative care should take place.
What is PPS (palliative performance scale)
Useful way of assessing and reviewing functional changes in palliative patients - excellent communication tool
Good prognsotic value
Limited use for patients demonstrating subtle changes in advanced dementia.
What do lower PPS scores at inital assessment indicate
What do falling PPS scores compared to patieents whose PPS scores remain static or improved imply
How are PPS scores determined
Poor prognosis
Increased risk of death compared with patients whose PPS scores remain static or improved
PPS scores are determined by reading horizontally at each level to find a ‘best fit’ for the patient who is then assigned as the PPS % score in 10% increments. Begin at leftward columns and read downwards
Understanding disease trajectories allows for…
- Discussion with the patient about how their illness will progress – help them gain control over their illness
- Early planning for care when nearing death including discussion regarding where they wish to die, DNR directives
- Significant challenges particularly in managing patients with the second trajectory.
Limitations to any disease trajectory model
- Patients may not follow it as concurrent illness or change in circumstances affect outcome
- Some illnesses don’t fit well e.g. stroke (depends on severity of stroke) or renal failure (steady decline determined by underlying condition)
- Does not map well for psychological or spiritual distress
Three different disease trajectories
-
1. e.g. cancer
- Anticipatory time, poor PPS towards final months
-
2. e.g. heart failure or COPD
- Unwell for months/years with acute, severe exacerbations
- Timing of death uncertain
-
3. e.g. dementia or generalized frailty
- Progressive disability from an already low baseline of cognitive or physical functioning
- Declining reserves among many other things.
Palliative care in primary care
- Practices have a register of palliative patients
- The practice team meet regularaly to discuss the cases
- Enhances communication between team members
- OOH also notified of palliative cases
You have identified that your patient needs palliative care…
What happens next?
- Begins with anticipatory care planning with patient and carers - planning what the patient wants for their future care.
- e.g. where do they want to be cared for?, do they want to be allowed to die naturally? etc.
- Once diagnoseed as at a palliative care stage of care, and these discussions have taken palce, they shoud be placed on the practice’s palliative care register - to enable/coordinate ongoing care.
- Plan then sent to out of hours service, regular pc meetings and regular reviews - PPS score determines how quickly situation is changing for the patient
Sympoms in palliative care
- Pain is often feared by patients
- No symptom should be ignored
- e.g. anxiety, insomnia, and nausea may all be significant and distressing symptoms.
- It is important to respond globally to the patient and his/her family
Preferred place of care
- Most people express the preference for a home death - 65%
- only 26% achieve this
- Most of the final year is spent at home however
- Gold standards framework offers tools to enable primary care to provide palliative care at home - these include seetting up a caner registry and reflective practice
% of deaths occurring in hospices
15-20% deaths occur in hospices depeending on the area
Form part of the multidisciplinary care team
Breaking bad news
- Listen
- Set the Scene
- Find out what the patient understands
- Find out how much the patient wants to know
- Share information using a common language
- Review and summarise
- Allow opportunities for questions
- Agree follow up and support
Aspects to a ‘good death’
- Pain-free death
- Open acknowledgement of the imminence of death
- Death at home surrounded by family and friends
- An ‘aware’ death, in which personal conflicts and unfinished business are resolved
- Death as personal growth
- Death according to personal preference and in a manner that resonates with the person’s individuality
Grief
- Is an individual experience
- Is a process that may take months or years
- Patients may need to be reassured that they are normal
- Abnormal or distorted reactions may need more help
- Bereavement is associated with morbidity and mortality
Euthanasia - what does it mean
- Means ‘gentle’ or ‘easy’ death
- Has now come to mean the deliberate ending of a persons life with or without their request
- Ilegal in the UK
- Mainly requested for unrelieved symptoms or the dread of further suffering
Define voluntary euthanasia
vs
non-voluntary euthanasia
vs
physician assisted suicide
Patient’s request
No requeset
Physician provides the means and the advice for suicide
Responses to requesting euthanasia
- Listen
- Acknowledge the issue
- Explore the reasons for the request
- Explore ways of giving more control to the patient
- Look for treatable problems
- Remember spiritual issues
- Admit powerlessness
