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Yr4: OPIC > Advanced Care Planning > Flashcards

Advanced Care Planning Flashcards

1
Q

What do we mean by mental capacity?

A

One’s own ability to make decisions (can be about personal welfare, health, financial etc..)

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2
Q

What is the aim of the mental capacity act?

A

Empowers people to make decisions for themselves where possible and protects people who lack capacity to make decisions about their own care and treatment by providing a flexible framework that puts the individual at the heart of the decision making process.

It covers decisions about day-to-day things like what to wear or what to buy for the weekly shop, or serious life-changing decisions like whether to move into a care home or have major surgery.

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3
Q

Where does the mental capacity act apply to?

A

England & Wales

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4
Q

Mental capacity is both time and decision specific; what does this mean?

A
  • Time specific: patients capacity may change over time hence you must reassess regularly
  • Decision specific: people may have the capacity to make one decision (e.g. what to wear) but not have the capacity to make another decision (e.g. whether to have life-saving treatment). Capacity must be assessed for each decision; it’s not as clear cut as ‘you have capacity or you don’t’
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5
Q

State the 5 principles of the Mental Capacity act

A
  • People must be given all appropriate help to make decisions before you decide they do not have capacity (e.g. use of visual aids, interpreters, multiple attempts if not time dependent as capacity can fluctuate)
  • Unwise decisions are allowed and it does not mean the person does not have capacity
  • Capacity is assumed until proven otherwise
  • Decisions made on behalf of individuals must be made in their best interests
  • Least restrictive option should be chosen
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6
Q

Outline the two stage capacity assessment

A

Stage 1

Is there an impairment of, or disturbance in the functioning of, the mind or brain?

Stage 2

If so, does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made? Can assess this using 4 key components:

  • Are they able to understand the information?
  • Can they retain the information long enough to make a decision?
  • Can they weigh up the information in the process of decision making?
  • Can they communicate that decision?
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7
Q

State some reasons why a person may lack capacity

A
  • Dementia
  • Severe learning disability
  • Brain injury
  • Stroke
  • Psychiatric illness
  • Unconscious
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8
Q

What is an independent mental capacity advocate (IMCA)?

A
  • Person appointed to support a person who lacks capacity but has no one to speak on their behalf (e.g. no NOK, power of attorney etc…)
  • Gather as much information about patient as possible, raise any concerns and produce a report representing the patient to help with best interest decision making
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9
Q

For DoLS (Deprivation of Liberty Safeguards) discuss:

  • Aims
  • Whether it is part of MCA
  • Which countries it applies in
  • How you get a DoLS?
  • What framework is replacing DoLS and how is this different to current DoLS?
A
  • Ensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty
  • Part of MCA
  • England & Wales (and only in hospitals & care homes. Separate system for those in supported living)
  • Must apply to local authorities who will carry out an assessment to see if deprivation of liberty is in patients best interests

**NOTE: DoLS framework will be replaced by a new scheme known as Liberty Protection Safeguards (LPS) in April 2022. Main changes to be aware of as medical student is that now applies to people 16yrs and over and applies in domestic settings. LPS applies in a person’s own home or family home, shared living and supported living, hospitals and care homes.

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10
Q

What is a deputy appointed by the court of protection?

What is the difference between a deputy appointed by the court of protection and a power of attorney?

A
  • Person can apply to be someone’s deputy if they lack mental capacity. Court of Protection will then authorise you to make decisions on patients behalf
  • An attorney can only be appointed whilst an individual has capacity to do so. A power of attorney allows an individual control over who is appointed as attorney and what powers they have. A deputy can only be appointed once an individual lacks capacity.
  • Like with Power of Attorney there are tow types: property & financial affairs, personal welfare deputy
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11
Q

What is a public guardian?

A
  • The role of the Public Guardian is to protect people who lack capacity from abuse
  • Guardian appointed by court and is supported in their duties by the Office of the Public Guardian (OPG)
  • Public guardians role includes:
    • Keeping records of deputies & attorneys and the information that they must submit
    • Supervising deputies & attorneys in their duties
    • Raising any concerns about deputies or attorney’s and their actions
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12
Q

What is an independent mental health advocate?

A

IMHAs are independent of mental health services and support people who are under the MHA to understand their rights and participate in decisions about their care & treatment. Roles include:

  • Make sure you opinions are heard
  • Help you make decisions
  • Help you understand your detention & treatment
  • Help in tribunals
  • Help you get the right help when you leave hospital
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13
Q

What is advanced care planning?

A

Care provider, the individual and those close to them discuss the pts wishes and priorities for future care

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14
Q

What is an advanced statement?

A
  • Statement, written or verbal, of the patients preferences, wishes and likely plans e.g. preferred place of death
  • NOT legally binding
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15
Q

What is a lasting power of attorney (LPA)?

State the two different types

A
  • Individual who has been appointed by patient, whilst they had capacity, to act on their behalf should they lose capacity
  • Can have LPA for:
    • Property & financial affairs
    • Health & welfare
  • LEGALLY BINDING
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16
Q

What is an advanced decision to refuse treatment?

A
  • Written statement of regarding what patient does not want to happen to them e.g. artificial nutrition, ventilation, CPR etc… which comes into force when capacity is lost
  • LEGALLY BINDING
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17
Q

Define a mental disorder

A

Any disorder or disability of the mind; it includes mental illness, personality disorder, learning disabilities, disorder of sexual preferences (e.g. paedophilia) but NOT dependence on drugs & alcohol

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18
Q

What is the purpose of the Mental Health act?

A

Allows people with a mental disorder to be sectioned, detained and treated (for their mental disorder) without their consent either for their own health & safety or for the protection of others. Numerous different sections within the MHA all of which allow different things. Applies in England & Wales only,

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19
Q

When should you use MHA?

*HINT: Revise Our Mental Health Act

A
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20
Q

For a section 2 discuss:

  • What it allows you to do
  • Who can/which professionals can reccommend a section 2
  • Appeals process
A
  • Allows you to admit & then detain pt for 28 days to allow for assessment & response to treatment
  • An AMHP makes the application on the recommendation of two doctors with at least one section 12 approved doctor
  • Can appeal to a tribunal during first 14 days (and to hospital managers at any time)
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21
Q

For a section 3 discuss:

  • What it allows you to do
  • Who can/which professionals can reccommend a section 3
  • Renewal
  • Appeals process
  • When they have to be seen by a SOAD (second opinion appointed doctor)
A
  • Allows you to admit and detain a pt for up to 6 months (but may be discharged before this). Can be detained under S3 if known to mental health services/have mental disorder or following admission under S2
  • An AMHP makes the application on the recommendation of two approved clinicians (doctors registrar level & above) with at least one section 12 approved doctor
  • Can be renewed for further 6 months. After that renew for periods of one year.
  • Can appeal to a tribunal ONCE during first 6 months. If S3 renewed then can appeal once during second 6 months. then appeal can be made once during each year. Can appeal to MHA managers at any time.
  • Can be treated against their will for 3 months but after this time must be seen by SOAD if still refusing treatment or lack capacity to see if treatment is needed
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22
Q

What is section 117 aftercare?

A

Section 117 aftercare is a legal duty that is placed on health and social services to provide after care services for individuals who have been detained under section 3, 37, 47, 48 and 45A.

This may involve support with healthcare, supported accomodation, employment etc..

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23
Q

There are 5 emergency sections; state these

A
  • Section 4
  • Section 5 (2)
  • Section 5 (4)
  • Section 135
  • Section 136
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24
Q

For a section 4, discuss:

  • When it is used
  • What it allows you to do
  • How long it lasts
  • Who it requires
  • Whether you can appeal
  • What usually happens following S4
A
  • Allows emergency admission of pts not already in hospital when waiting for personnel or paperwork to complete S2 would cause dangerous delay
  • Allows you to detain pt but NOT treat
  • 72hrs
  • Only requires one doctor (who doesn’t need to be section 12 approved- it is often GP). Application made by NR or AMHP
  • No right to appeal
  • Usually converted into S2 upon arrival
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25
Q

For a section 5(2) discuss:

  • Why & where it can be used
  • What it allows you to do
  • How long it lasts for
  • Who it requires
  • What should happen in that time
  • Right to appeal
    *
A
  • Urgent detention of pts on any ward (excluding A&E).
  • Does not allow you to treat only detain
  • 72hrs
  • Doctor (does not need to be section 12 approved but has to be the consultant or nominated deputy- in most psych wards this is core psychiatric trainee on call)
  • Assessed for a S2, S3 or discharge from 5 (2) to become informal
  • No right to appeal
26
Q

For a section 5 (4) discuss:

  • What it allows
  • How long it lasts
  • Who can do it
  • Right to appeal
A
  • Urgent detention of an inpatient already receiving treatment for a mental disorder, as an informal pt, in hospital
  • Up to 6hrs
  • Registered mental health nurse when doctor unable to attend immediately
  • No right to appeal
27
Q

For a section 135, discuss:

  • What it allows
A

Allows a police officer or authorised person with a magistrates warrant to enter a person’s premises, who is suspected to be suffering from a mental disorder, and remove them to a place of safety

28
Q

For a section 136, dicuss:

  • What it allows
A

Allows a police officer to remove an individual who appears to suffer from a mental disorder from a public place to a place of safety for assessment

29
Q

State 3 places of safety

A
  • Police station
  • A&E
  • Place of safety at mental health unit
30
Q

Briefly summarise some of the other following sections:

  • Section 17
  • Section 35-38
  • Section 7 (guardianship)
  • Section 62
A
  • Section 17= allows pts udner S3 to go on leave from hospital
  • Section 35-38= used by a court to send offenders to hospital for psychiatric assessment
  • Section 7 (guardianship)= gives power to specifiy where a pt lives and requires them to give professionals involved in their care access to their home
  • Section 62= urgent treatments such as ECT for life threatening depression
31
Q

What is a CTO?

A
  • Community treatment order
  • Can be used for pts who were on S3 when they leave hospital
  • Under a CTO pt can be recalled back to hospital if they don’t comply with treatment or attend appointments
  • Once recalled they can be detained for up to 72hrs for assessment
32
Q

You cannot use a section 5(2) or 5(4) in A&E as not classed as inpatient; hence, what could you do if you cannot let them leave?

A

Call security and not let them leave until…?CHECK

33
Q

Summary of main civil sections

A
34
Q

What is the difference between advanced decision to refuse treatment and DNA-CPR?

A
  • ADRT is patient choice
  • DNA-CPR is ultimately responsible doctors choice (if pt wants CPR but Dr disagrees they can override it)
35
Q

Briefly outline what is involved in a ReSPECT form

A

A ReSPECT form is not legally binding and focuses only on making recommendations about care and treatment that might be considered in an emergency.

36
Q

What is meant by ceiling of care?

In what patients may it be appropriate to establish a ceiling of care?

A
  • Ceiling of treatment/care is considered to be the predetermined highest level of intervention deemed appropriate by a medical team, aligning with patient and family wishes, values and beliefs. These crucial early decisions aim to improve the quality of care for patients in whom they are deemed appropriate.
  • Example patients: end of life, complex/multi-morbidity, poor quality of life
37
Q

What do we mean by ageism in healthcare?

How can it be avoided?

A

Ageism is prejudice or discrimination against people based on their age. It typically applies to people who are older but can also affect young people. Examples in healthcare:

  • Infantilising patients: e.g. talking to elderly people with over-simplified language, using endearing terms, using rhythmic tone one might use for a child
  • Inaccurate perception of ageing: e.g. assuming they aren’t capable because of their age
  • Over- or under-treating due to age: e.g. prescribing abx because leucocytes on urine dipstick with no UTI symptoms or not treating depression because ‘it’s normal to be depressed when you are old’

Some methods to help avoid ageism in healthcare:

  • Get to know your patient. Don’t assume every elderly person is deaf, needs a stick etc…
  • Acknowledge any family/care givers but focus on the elderly person as they are still your patient
  • Don’t use ‘elderspeak’ speak to them like they are an infant
38
Q

Following cards copied directly form Yr4 Cancer Care: EoL Care

A
39
Q

What is palliative care?

A

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems and of physical, psychosocial and spiritual problems.

40
Q

What do we mean by end of life care?

A

Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:

  • Advanced, progressive, incurable conditions
  • General frailty and co-existing conditions that mean they are expected to die within 12 months
  • Existing conditions if they are at risk of dying from a sudden acute crisis in their condition
  • Life-threatening acute conditions caused by sudden catastrophic event
41
Q

Describe some example trajectories for the following life-limiting illnesses:

  • ESRD
  • Cancer
  • Cardiac/resp failure
  • Frailty
A
42
Q

Remind yourself of the clinical frailty scale

A
43
Q

What tool can be used to help identify people whose health is deteriorating?

Briefly describe this tool

A

SPICT (Supportive & Palliative Care Indicator Tool)

Helps to identify people with deteriorating health due to advanced conditions or a serious illness and prompts holistic assessment and future care planning.

**Be sure you can list a few indicators of general decline/deteriorating health

44
Q

State some potential barriers to recognising deterioration

A
45
Q

Alongside the SPICT, Gold Standards Framework Prognostic Indicator can be used in primary care; briefly explain this guidance

*HINT: 3 parts

A

GSF is a UK based training primary care initiative to improve end of life care

46
Q

State some factors that may indicate a pt is going to die imminently

A
47
Q

State some common symptoms experienced in people who are dying

A
  • Pain
  • Nausea & vomiting
  • Breathlessness
  • Restlessness & agitation
  • Respiratory tract secretions “death rattle”
  • Confusion
  • Constipation
  • Dry mouth/xerostomia
  • Hiccups
  • Itch
  • Anorexia
48
Q

Discuss the management of reduced food and fluid intake in pts who are dying

A
  • Supported to eat & drink as long as they wish to do so
  • Consider IV fluids/CAH (clinically assisted hydration); a lot to consider as more evidence is needed regarding whether it should be used in palliative care:
    • Must share uncertainty around whether CAH will prolong life or extend dying process
    • Discuss that it may relieve some symptoms
    • … but may also cause other problems
    • Regular mouth care must be given
    • Assess hydration status daily

The key question to answer is “will the treatment be of overall benefit to the pt”. You may not be sure of this answer and in this case you should start fluids and reassess/review… be sure to document this is what you are doing

49
Q

Discuss the management of N&V in pts who are dying

A

(See management of other symptoms for full info)

  • Basic measures e.g. small frequent meals, avoid smell of food, acupressure bands…
  • If underlying cause (e.g. electrolyte abnormality detected) correct
  • Antiemetics
    • Different classes recommended based on cause
    • Levomepromazine is a good broad spectrum antiemetic and is the drug of choice in anticipatory prescribing for N&V

Summary from UHL Guidelines Palliative Prescribing

  • Metabolic/drug induced: Haloperidol 500microgram - 1mg oral or via subcutaneous injection once to twice daily
  • Raised ICP= cyclizine 50mg oral three times per day
  • Gastric stasis= Metoclopramide 10mg oral three times per day
  • Second line when haloperidol / cyclizine / metoclopramide have not worked, or where the cause of nausea and vomiting is unclear:
    • Levomepromazine 6.25mg oral or via subcutaneous injection once to twice daily
50
Q

Discuss the management of pain in pts who are dying

A

(See pain assessment & management FC for full details)

  • Non-pharmacological: repositioning etc…
  • WHO pain ladder
    • Opioid naïve: start at about 2.5mg - 5mg PO PRN up to hourly . If this controls pain, consider conversion to morphine sulphate modified-release (MR) twice daily

Image from UHL guidelines palliative prescribing

51
Q

Discuss the management of breathlessness in pts who are dying

A
  • Non pharmacological: prone position, calm environment with reassuring professionals, reduce room temperature, cool flannel to face, open window, fan
  • Trial of oxygen if sats <92%
  • Opioids (low dose)
    • Opioid naïve pts: PO morphine sulphate 2.5mg-5mg PRN up to hourly
    • Established on opioids: give ½ PRN dose for pain (e.g. 10mg PRN for pain, 5mg PRN for dyspnoea)
    • If effective can give modified release (up to 30mg for breathlessness)
  • Anxiolytics
    • Lorazepam 500micrograms-1mg PO PRN, max 4mg/24hr
    • Midazolam 2.5-5mg SC PRN up to hourly
52
Q

Discuss the management of restlessness & agitation in pts who are dying

A
  • Non-pharmacological: try to find and resolve cause, family, calm environment, reduce number of people around, spiritual support, relaxation techniques
  • Midazolam 2.5mg-5mg SC PRN 1-2hrly
  • Levomepromazine 6.25-12.5mg SC, 2-4hrly, max 50mg/24hr
53
Q

Discuss the management of respiratory tract secretions in pts who are dying

A
  • Non-pharmacological: position pt to allow gravity to move secretions, stop or reduce volume of IV/PEG feeds and/or IV/SC fluids
  • Glycopyrronium 200micrograms SC PRN up to 4hrs (max dose 1.2mg/24hr)
54
Q

What do we mean by anticipatory prescribing?

A

Prescribe medications, to treat common/expected symptoms when dying, even when pt hasn’t got symptoms; enables prompt symptom relief at whatever time the patient develops distressing symptoms.

55
Q

What drugs are prescribed as part of anticipatory prescribing in the dying? Include dose, frequency and route

*NEED TO KNOW, CAN BE ASKED IN EXAM

A

SUMMARY OF WHAT TO KNOW

**IF can’t take opioids PO then can half of PO dose

56
Q

Discuss the management of delirium in patients who are dying

A
  • Non-pharmacological: calm atmosphere, increased supervision, continuity with environment/routine/staff, ask family for advice, minimise distress, normal sleep-wake cycle, familiar objects, identify & treat any known causes
  • Few pharmacological options:
    • In non-terminal phase: first choice Haloperidol (500micrograms PRN PO up to 2hrly, max 5mg/24hrs) or Lorazepam (500micrograms-1mg PO PRN max 4mg/24hr)
    • In last few days/hrs:
      • Midazolam 2.5-5mg SC PRN, 1-2hrly
      • Levomepromazine 6.25mg-12.5mg SC PRN, 2-4hrly max 50mg/24hr
57
Q

Discuss the management of cough in a dying patient

A
  • Non-pharmacological: oral fluids e.g. honey & lemon in water, cough sweets, elevate head/sleep with pillows
  • Codeine linctus 30-60mg PO QDS
  • Oral morphine sulphate 2.5mg PO 4hrly
58
Q

Why might a pt need palliative care input alongside active disease management?

A
  • Help manage symptoms
  • Plan ahead
  • Help educate them about options available
  • Help prepare pts & family for death
59
Q

Discuss the management of hiccups in a dying patient

A
  • Chlorpromazine
  • Others that may be used:
    • Haloperidol
    • Gabapentin
    • Dexamethasone (particularly if there are hepatic lesions)
60
Q

What does STOPP START stand for?

A
61
Q

What patient group is the STOPP START tool to be used in?

A

Aged 65 or over

62
Q

What that the aims of the STOPP START tool?

A
  • Highlight and prevent inappropriate prescribing
  • Redution in DDIs and/or ADRs

*Like anything, must always use the tool in conjunction with your clinical judgement

Yr4: OPIC (11 decks)

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