End Of Life

Question 1

Liverpool care pathway

Answer 1

Recognising that a person was dying was not always supported by an experienced clinician and not reliably reviewed
The dying person may have been unduly sedated as a result of too much medication
Perception that hydration and some medication may have been withheld or withdrawn

Was not direct consequence of pathway but often happened because of poor training, poor supervision

Question 2

Ambitions for palliative and end of life care 2015-2020

Answer 2

Each person is seen as individual 
Each person gets fair access to care 
Maximising comfort and wellbeing 
Care is coordinated 
All staff are prepared to care 
Each community is prepared to help

Question 3

Leadership alliance for the care of dying people 2014

Answer 3

5 priorities for care:

• Possibility that a person may die in coming days is recognised and communicated clearly, decision made in accordance with the persons need and wishes
• Sensitive communication takes place between staff, person dying and family
• dying person and family are involved in decisions and treatments
• family is listened to
• care is tailored specifically and delivered with compassion

Question 4

Department of health - our commitment to you and end of life care 2016

Answer 4

3 main areas - 
Treat the patient with dignity 
All care to be compassionate 
Reflect on care delivered 
5 key aims 
- aims to give a good death 
- live well until you die 
- informed choices 
- personalised care plans 
- respect patient wishes

Question 5

NICE guidelines (NG31) - care of dying adult

Answer 5

Recognise when people are entering the last few days of life
Communicating and shared decision making
Clinically assisted hydration
Medicines for managing pain, breathlessness, agitation, nausea
Anticipatory prescribing

Question 6

The route to success in end of life care - achieving quality in ambulance service 2012 GSF

Answer 6

• GSF is a systemic evidence based approach to optimising care for people in last year of life with any condition in any setting
• outlines a process to help clinicians
• tools for flagging people who have increased care needs
• identification, right through to discharge home or care in final days
• has 7 steps (the 7cs)

Question 7

7 C’s to gold standard framework

Answer 7

Communication 
Coordination 
Control of symptoms 
Continuity of Care 
Continued learning 
Cared support 
Care in the dying phase

Question 8

3 step process to GSF

Answer 8

Identify
- life expectancy 6-12 months
Assess
- clarification of patient needs and support required
- discuss goals and wishes
- recognised the patient is nearing end of life communicate with relevant teams
Plan
- crisis prevention allows patients to live well till death
- advanced care plan, dnacpr
-utilisation of community services

Question 9

What is palliative care

Answer 9

An approach that improves the quality of life of patients and their families facing the problems associated with illness. Can be done through preventing and relief of suffering by means of early identification, assessment, treatment of pain and other problems

Question 10

What is end of life

Answer 10

Likely to die within 12 months
Includes pt whose death is imminent
- advanced, progressive, incurable conditions
- general frailty and coexisting conditions expected to die within 12 months
- acute crisis of existing condition
- life threatening condition cause by catastrophic event

Question 11

End of life vs palliative care

Answer 11

Palliative Care aims to decrease suffering with a condition, end of life is comfort care provided to those facing the end of their life

Question 12

Signs of end of life patient

Answer 12

Cold peripheries 
Altered breathing 
Temperature 
Confusion 
Incontinence 
Restlessness
Congestion 
Reduced urine output 
Increased sleep

Question 13

Behaviours for end of life

Answer 13

Pre planning 
Saying goodbye 
Communication change 
Hallucinations 
Behavioural changes

Question 14

1-3 months signs and symptoms of end of life

Answer 14

Reduced appetite
Decreased fluid tolerance
Social withdrawal
Prolonged periods of rest and immobility

Question 15

1-2 weeks signs and symptoms end of life

Answer 15

Increased sleep 
Restlessness 
Increased confusion 
Hallucinations 
Physiological changes 
Complete intolerance for food 
Breathing more congested

Question 16

1-7 days

Answer 16

Hypotension 
Weak thready pulse 
Decreased responsiveness 
Increased restlessness 
Intermittent energy spells 
Glazed eyes 
Hands and feet may appear blotchy cold to touch 
Urine output decreased

Question 17

Last minutes of life signs and symptoms

Answer 17

Patient no longer able to respond

Breathing pattern becomes gasping

Question 18

Aims of palliative care

Answer 18

• affirm life and regard dying as normal process
• provide relief from pain and other symptoms
• integrate psychological and spiritual aspects of patient care
• offer a support system to help patient live as actively as possible till death
• offer a support system for family

Question 19

6 questions to ask end of life patient

Answer 19

1. What is understanding of illness
2. Are you receiving or due to receive any medical treatment ?
3. Is there documentation/ other services involved?
4. Would you want to manage at home
5. What local services are available?
6. What do we need to do next / tomorrow ?

Question 20

What is anticipatory prescribing ?

Answer 20

They are just in case medications for cases such as breakthrough pain and get timely access to medications
Designed so drugs in patients home

Drugs should be clearly marked, and have means for recording administration
We do not do syringe driver

Question 21

Dyspnoea in end of life

Answer 21

Severely impacted quality of life, often psychological. Discomfort may vary and may not be associated with hypoxia, tachypnea or Bradypnea
Listen to patient description

Question 22

Non-pharmacological management for dyspnoea

Answer 22

Positioning
Airflow - use fan or window
Relaxation, distraction, reassurance
Controller breathing technique

Question 23

Pharmacological treatment for dyspnoea

Answer 23

Opioids
Sensitivity of the respiratory centre to stimulation by carbon dioxide is reduced by morphine
Resp centre is area rich with opioid receptors

Question 24

Paramedic options

Answer 24

Oral, sc or IM morphine
Safety net ensure review by gp, district nurse, ooh, palliative care team
Anticipatory medication
Out of hours gp review

Question 25

Pain in end of life

Answer 25

Present with many patients, especially cancer. Patient may have breakout or breakthrough pain needs extra treatment

Pain scores, consider abbey pain scale, consider pain relief already taken, consider opiate naive or established, leave patches in situ, do not alter syringe drivers

Question 26

Myoclonic twitching and jerking

Answer 26

Not uncommon in dying patient and may reflect accumulation of excitatory opioid metabolites causing involuntary jerking

Common in renal failure

May be distressing for patients and their families, explain and phone for review or hospice help line

Question 27

Pharmacological interventions for pain

Answer 27

IM/SC morphine usually start 2.5-5mg if not on opiates. If Is already for breakthrough pain 1/6th of daily dose

Iv pain for bone pain

Caution below 90mmhg

Question 28

Factors to take into consideration when pharmacological interventions for pain in end of life

Answer 28

Do not dilute the morphine 
Check previous administration 
4 hours for paracetamol, 6 hours if renal 
Effects of im/sc morphine 15-20 mins 
Paracetamol over 15 minutes 
Inform own gp or palliative team

Question 29

Terminal agitation/ restlessness in end of life

Answer 29

Normal at end of life important to treat
If not immediately dying try to reverse treatable factors
Irreversible can affect quality of life

NICE (NG31) provides guidance suggest to consider benzodiazepines such as Midazolam inform family this may cause to loc

Question 30

Moist and noisy secretions in end of life

Answer 30

Secretions may accumulate in the airway and resulting in gurgling and rattling
17 -57 hours before death
Reposition patient
Consider drug therapy - hyoscine bromide, hyoscine butylbromide- administer and record

Question 31

Nause and vomiting in end of life

Answer 31

Occurs in many patients
Recommended levomepromazine
May be another anti emetic
If giving JRCALC drug seek advice from palliative care team

Question 32

What is a palliative care emergency

Answer 32

Conditions which left untreated will seriously threaten the quality of life remaining. Reversibility needs to be considered in conjunction with patient wishes.

• wishes of patient and family
• nature of emergency
• stage of illness and prognosis
• comorbidities and symptoms
• likely effectiveness of treatment

Question 33

What are reversible causes in end of life

Answer 33

Infection 
Hypercalcaemia 
Medication changes 
Treatment consequences 
Palliative emergencies

Question 34

Palliative emergencies examples

Answer 34

Metastatic spinal cord compression(mssc) 
Superior vena cava compression 
Neutropenic sepsis 
Pathological fractures 
Seizures 
Hypoglycaemia 
Drug toxicity 
Pain crisis 
Resp crisis 
Anaphylaxis

Question 35

What is metastatic spinal cord compression

Answer 35

Spinal cord compression due to direct pressure or collapse of the vertebral body due to spinal metastases result in vascular injury, cord necrosis and neurological injury

Occurs within any part of spine
Common in cancer especially lymphoma and myeloma

Question 36

Symptoms of metastatic spinal cord compression

Answer 36

Neurological signs (upper/lower/minor sensory/ asymmetric)
Pain - thoracic/cervical/ progress lumbar/ prevents sleep/ aggravated by straining sneezing/ localised spine tenderness/ radicular pain
Stiffness and weakness
Sensory loss
Urinary symptoms- retention/ incontinence

Question 37

What is radicular pain

Answer 37

Band pain round the body occurs in metastatic spinal cord compression

Question 38

Late symptoms of metastatic spinal cord compression

Answer 38

Peri-anal numbness and lack of anal tone
Not being able to open or control bladder or bowels
Priapism

Question 39

Management of metastatic spinal cord compression

Answer 39

Needs to be review urgently
Specialist treatment - involves administration steroids, will need neurological exam and mri
Treatment involves - radiotherapy/ surgery

Paramedic management - abcd problems, limit mobility, JRCALC pain management

Question 40

What is superior vena cava compression

Answer 40

Occlusion of the superior vena cava due to either external compression or internal obstruction
Most commonly caused by cancers
Severity of symptoms varies depending on degrees of obstruction

Question 41

Signs and symptoms of superior vena cava compression

Answer 41

Venous distention in neck and chest 
Facial, neck swelling when lying down or bending over 
Proptosis (bulging eyes) 
Stridor 
Cough/ hoarseness 
Dyspnoea 
Headache 
Nasal congestion/ epistaxis 
Haemoptysis

Question 42

Management/ treatment options for Superior vena cava compression

Answer 42

Requires urgent management pathway
Manage symptoms e.g. give oxygen
Administer corticosteroids and diuretics where upper airway oedema decreased cardiac output and brain oedema is present

Sit the patient upright and elevate the head

Question 43

What is neutropenic sepsis

Answer 43

Potentially fatal complication of anti cancer treatment
These therapies to treat cancer can suppress the ability of bone marrow to respond to infection
Would suspect neutropenic sepsis in patients having anti cancer treatment who become unwell
Often occur between 7 and 12 days is when white blood cell at their lowest

Question 44

Signs and symptoms of neutropenic sepsis

Answer 44

Temp more than 37.5 or less than 36 
Minor illness or feels unwell 
Tachypnoea 
Tachycardia 
Hypotension 
Chest pain 
Flu-like symptoms 
Gum or nose bleeds 
Vomiting 
Diarrhoea 
Bruising 
Catheter site infection (neutropenic patients are unable to produce pjs)

Question 45

Management and treatment for neutropenic sepsis

Answer 45

Manage according to JRCALC guidelines

All should be transported to hospital

Question 46

What is a respect form

Answer 46

It is a process that creates personalised recommendations for a persons clinical care in a future emergency

Must be a 2 way discussion between patient and healthcare professional, form must be kept with pt at all times

Question 47

Points to respect form

Answer 47

Is proactive not reactive 
Is personalised 
Involves more than just 1 person 
About more than the cpr decision 
Applies nationally in all setting 
Has been developed by national experts and the public

Question 48

Key stages to the respect form

Answer 48

1. Understand - establish a shared understanding of the person state of Health and medical conditions
2. Set goals - to establish what is important to the person and what they see as main focus of their treatment
3. Plan - to discuss treatments that should be considered as well as treatments which they may not want or may not help

Question 49

Relate respect form to other forms

Answer 49

ADRT - this is legally binding but respect form is not
ACP (anticipatory care plan) - other preferences such as funeral
End of life care plan - record a persons individual care and treatment leading up to death
CYPACP - childs advanced care plan

Question 50

Law and ethics of the respect form

Answer 50

The respect form is not legally binding they are designed to guide immediate decision making by health care professionals who to respond to people in crisis
Think best interest

Question 51

What’s should look for on respect form

Answer 51

Personal preferences priorities
2 boxes for clinical recommendations only one signed if both act best interest
Capacity
Clinical signature - makes it valid