Conservative care and role of active and supportive treatment Flashcards
Why is it bad that we don’t we let people die?
The medical profession is too focused on the ‘war on disease’ to give adequate time to end-of-life care
Patients dying in hospitals often receive inadequate end-of-life care because doctors are scared of asking them about their needs and discussing death, experts have said.
What is the definition of supportive care?
Care that helps patient and family to cope with condition and its treatment
- from prediagnosis
- through diagnosis and treatment
- to cure, continuing illness or death
- into bereavement
Helps patient maximise benefits of treatment and to live as well as possible with effects of disease
As important as diagnosis and treatment
What is palliative care?
Palliative care is care which enables people with progressive, and/or life threatening conditions or who are approaching the end of life to live according to their wishes and preferences wherever possible
How do we achieve aims of supportive care?
Communication with patient and family
- Patient and family expectations and wishes
- Symptoms and pain control
- Realistic prognosis
Awareness of patient being near end of life
Advance care planning
Appropriate active interventions, e.g., antibiotics, dialysis, ventilation – and discussing withdrawal where appropriate – or not starting
What is the patient perspective of starting dialysis?
Relief of symptoms
Achieve quality of life goals
- Social and family interactions
- Physical activity: travel, work, exercise, self-care
- Mental activity: work, hobbies
Extend life with good quality
Avoid complications of treatment
What is the physicians pesrpective on starting dialysis?
Sick patient – have to do something
Meets criteria for starting dialysis
Belief that dialysis will benefit patient
Spaces available in HD unit – need filling
particularly important in private sector
Patient may not do well, but lets give dialysis a try
What are the factors to consider when older people are on dialysis?
Multiple comorbidities Physical function Cognitive function Nutritional status Depression Social isolation Vision Hearing Social support
What is scored to determine prognosis in >75 yrs patients on dialysis?
Body mass index <18.5 kg/m2 (1 point)
Congestive heart failure stages III-IV (2 points)
Peripheral vascular disease stages III-IV (2 points)
Dysrhythmia (1 point)
Active malignancy (1 point)
Severe behavioural disorder (2 points)
Total dependency for transfers (3 points)
Unplanned dialysis (2 points)
How does autonomy affect the decision of dialysis?
Patients must be given realistic and accurate information to enable them to make appropriate decision
Patients cannot demand treatment if not appropriate
Not relevant if patient lacks capacity
How does benificence affect decision of dialysis?
i.e. dialysis should benefit patient
Prolongs survival
Improves quality of life
Improves symptom burden
How does non maleficence affect the decision of dialysis?
i.e. dialysis should not harm patient
Shortens survival
No improvement or worse quality of life
Increases symptom burden
How does justice affect the decision of dialysis?
Limited resources in all healthcare systems
Dialysing patients who would not benefit leads to
- Dialysis staff/machines not being available for patient who may benefit
- Money/resources not being available for other healthcare needs
What is conservative care?
Non-dialysis pathway chosen by patient after shared decision making with predialysis team
Active management of anaemia with ESA and intravenous iron
BP control – slow rate of decline and lower stroke risk
Optimise fluid balance – avoid over and under hydration
Symptom control, including pain
Joint management with palliative care team at end of life phase
