End of Life Flashcards
what are the outcomes for graduates?
(What the GMC says you should be able to do by the time you are graduating and starting work)
Summarise:
- the current ethical dilemmas in medical science and healthcare practice;
- the ethical issues that can arise in everyday clinical decision-making;
Apply ethical reasoning to situations which may be encountered in the first years after graduation
Demonstrate … appropriate clinical judgements when considering or providing compassionate interventions or support for patients who are nearing or at the end of life.
Understand the need to involve patients, their relatives, carers or other advocates in management decisions, making referrals and seeking advice from colleagues as appropriate
Are mortality rates changing?
Nope, still 100%
‘Death is a universal outcome, not a medical failure.
Dying badly, however, is often down to medical failure.’
What we are dying from has changed, how has it?
- Less common to die quickly
- Rise in co-morbidities + frailty
Has the concept of a good death changed?
- Faith cultures (rites/rituals)
- Individualist society + promotion of personal autonomy
- Multicultural society, multiple beliefs
- Informed choice, anticipatory care planning
what makes a good death?
- Communication - patient, carers/relatives, healthcare team
- Symptoms well controlled
- Not distressing
- Time to plan
- Preferred place of death
what makes a bad death?
- Poor communication
- Perception of failure of healthcare team
- Distressing symptoms
- Sudden
- Catastrophic event, e.g. bleed
- No time to plan ahead or achieve goals
- Disagreement
where do people want to die?
What are Preferred Place of death, last 3months of life?
- Office National Statistics
- National Survey of Bereaved Ppl
- England, 2015
Where do people die?
Percentage of deaths (persons, all ages) in hospital, care home, home and hospice, England, 2004 to 2016
what is quality of life enhanced by?
- Caring attitude of staff
- Family visits
- Physical environment
- Maintaining control
- Feeling safe/not alone
- Art sessions
- Smoking ?
what is quality of life diminished by?
- Lost independence
- Lost activities
- Pain/fear of pain
- Feeling a burden
Scenario 1 - Sandra
- Sandra is 57
- Life long smoker and is admitted electively for an endobronchial ultrasound guided biopsy (EBUS) of a lung mass
- Unfortunately, she develops pneumothorax and requires further inpatient treatment
- MDT happens and patient attends OP oncology clinic with her husband to discuss ongoing management and returns to the ward
- The oncologist kindly makes some notes on TRAK care which include details relating to prognosis (not discussed with the patient)
- As the FY2 on late shift, the nursing staff page you to speak with Sandra’s daughter
- You have been looking after Sandra, but have never met her daughter as she works full time
- You read through the notes to remind yourself of the details of the case and go to see Sandra and her daughter, who as been moved to a side room for infection control reasons (previous VRE in urine)
During the consultation, Sandra’s daughter asks, ‘so how long has she got?’ looking to her mother. Do you…
A) Quote the oncologist from the notes - 9 months.
B) Ask Sandra if she would like to know the answer
C) Tell the daughter while Sandra’s in the toilet
D) Explore Sandra’s ideas about her prognosis
E) Dodge the question…
B and D but also E. if you do not feel comfortable having a conversation with her
do people request for prognosis?
Many patients do want to know their prognosis, others will not:
- Non-maleficence
- Beneficence
Often families will want to know more than the patients:
- Respect autonomy
- Confidentiality
Giving the ‘gist’ rather than statistics
Scenario 2 - Mary
- Mary is 84 and is admitted to hospital with painless jaundice
- A CT reveals metastatic pancreatic cancer. There are no treatment options
- Mary’s daughter Beth asks you not to tell Mary the CT results
- She fears that Mary will ‘turn her face to the wall’ and may die more quickly
Do you tell the patient, Mary, that she has pancreatic cancer?
A) Yes
B) No
C) On the fence
A
when deciing whether to disclose to mary whether or not she has cancer what do you need to think about?
- Capacity
- Benefit/best interest
- Autonomy
- What if the daughter has Power of Attorney?
- What if the patient lacks capacity?
what is Collusion?
Collusion refers to a secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient
Possible reasons for collusion need to be established
The next task is to establish the patient’s level of awareness by asking relevant and direct questions which elicits his view of what may be happening to him through the cues provided by the patient
This process helps break the barriers between the patient and relatives
What are some reasons families may wish to collude?
- Disclosure causes the patient to lose hope
- Disclosure leads to depression
- Disclosure hastens the progression of the illness and death
- Disclosure increases the risk of patient suicide
- Disclosure may cause psychological pain for the patient
- Family members themselves may not be aware of the nature and severity of the illness
- Family members may be in denial
- Family members may be in conflict
Why collusion goes against the principles of best clinical practice in relation to patient factors
- Collusion is at odds patient autonomy and to the right to self-determination
- Revealing the diagnosis to relatives before revealing it to patients breaches patients’ right to medical confidentiality
- Patients are unable to give informed consent if they are not aware of the underlying illness and thus may not obtain appropriate or optimum and timely treatment
- Patients may not be able to complete unfinished business and tasks prior to their deaths
- Patients who sense something amiss may come to distrust their relatives and clinicians
- Many patients suspect the diagnosis anyway, given their symptoms and physical deterioration
Why collusion goes against the principles of best clinical practice in relation to family factors
- Family members will have to bear the burden of being untruthful or even deceptive to their loved ones, which may lead to guilt later
- A barrier to communication is erected as family members become avoidant at a time when they are most needed by patients
- Families will have no guidance in making treatment decisions, especially closer to the end of life
Why collusion goes against the principles of best clinical practice in relation to clinician factors
- Collusion results in a breakdown of the clinician–patient relationship and a loss of trust between patients and clinicians
- Clinicians may face treatment non-compliance from patients and may be unable to provide optimal treatment, such as radiotherapy and chemotherapy
Scenario 3 - Janet
- 63yo care home manager
- Diagnosed with Lung Cancer in Feb, given prognosis of 9 months
- smoker, COPD
- 2 weeks on, involved in RTA
- C-spine fracture, transferred to neuro HDU
- Required ventilation (non-invasive)
- Type 2 respiratory failure, COPD + sepsis secondary to pneumonia
- Weaning ventilation unsuccessful
- Oncologist opinion sought prognosis – best case scenario, ‘a few months
- Clinical Goal of Treatment - wean off ventilation
- Clinical team raised question of cardiopulmonary resuscitation
- Decision was made by a consultant intensivist to complete a DNACPR form
- Janet has been communicating with family by writing notes
- She has expressed her wishes to persevere with treatments and to ‘receive full active treatment’
Do you agree with the decision that Janet should have a DNACPR form completed?
A) Yes
B) No
C) I’m on the fence…
- Successfully weaned off ventilation
- Discharged home with the DNACPR form
- Daughter finds the form at home and is ‘horrified’.
- DNACPR form rescinded by the GP due to:
- The patient’s wish
- The families wishes
- Janet is now refusing to discuss resuscitation
- Refused to discuss her care or prognosis with palliative care team
- March - Janet’s condition starts to deteriorate
- Following further discussion, a DNACPR from was issued
- The family are in agreement
- Janet died on 7th March
- Her husband, David, pursued a claim against the NHS health board for breech of her Human Rights, Article 8
- In placing the first DNACPR notice, there was failure to adequately:
- Consult Janet or members of her family
- Notify her of the decision to impose the notice
- Offer her a second opinion
Are DNACPR forms a legal document and who are they for?
- Not a legal document
- Record of a decision
- Provide guidance for clinicians who do not know the patient - Who may be summoned to assess patient in an emergency
- Document decision in notes - If not discussed with patient, need to document rationale in notes
do patients need to be aware of DNACPR forms? and what if the patient lacks capacity?
- Patients must be made aware of DNACPR form unless there is ‘psychological or physical harm’
- What if the patient lacks capacity? - Must inform those close to the patient, without delay, unless it is ‘not practical or appropriate’
When there is clinical certainty DNACPR will remain in place - Does NOT need to be reviewed
what are the trends in patient characteristics for in hospital cardiac arrests?
Out of Hospital Cardiac Arrests
Mean age 64
