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End Of Life Flashcards

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1
Q

Liverpool care pathway

A

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Perception that hydration and some medication may have been withheld or withdrawn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

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2
Q

Ambitions for palliative and end of life care 2015-2020

A 
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
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3
Q

Leadership alliance for the care of dying people 2014

A

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
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4
Q

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

A 
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
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5
Q

NICE guidelines (NG31) - care of dying adult

A

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

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6
Q

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

A
  • 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)
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7
Q

7 C’s to gold standard framework

A 
Communication 
Coordination 
Control of symptoms 
Continuity of Care 
Continued learning 
Cared support 
Care in the dying phase
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8
Q

3 step process to GSF

A

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

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9
Q

What is palliative care

A

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

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10
Q

What is end of life

A

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

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11
Q

End of life vs palliative care

A

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

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12
Q

Signs of end of life patient

A 
Cold peripheries 
Altered breathing 
Temperature 
Confusion 
Incontinence 
Restlessness
Congestion 
Reduced urine output 
Increased sleep
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13
Q

Behaviours for end of life

A 
Pre planning 
Saying goodbye 
Communication change 
Hallucinations 
Behavioural changes
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14
Q

1-3 months signs and symptoms of end of life

A

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

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15
Q

1-2 weeks signs and symptoms end of life

A 
Increased sleep 
Restlessness 
Increased confusion 
Hallucinations 
Physiological changes 
Complete intolerance for food 
Breathing more congested
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16
Q

1-7 days

A 
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
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17
Q

Last minutes of life signs and symptoms

A

Patient no longer able to respond

Breathing pattern becomes gasping

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18
Q

Aims of palliative care

A
  • 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
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19
Q

6 questions to ask end of life patient

A
  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 ?
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20
Q

What is anticipatory prescribing ?

A

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

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21
Q

Dyspnoea in end of life

Study These Flashcards
A

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

22
Q

Non-pharmacological management for dyspnoea

Study These Flashcards
A

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

23
Q

Pharmacological treatment for dyspnoea

Study These Flashcards
A

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

24
Q

Paramedic options

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A

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

25
Pain in end of life
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
26
Myoclonic twitching and jerking
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
27
Pharmacological interventions for pain
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
28
Factors to take into consideration when pharmacological interventions for pain in end of life
``` 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 ```
29
Terminal agitation/ restlessness in end of life
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
30
Moist and noisy secretions in end of life
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
31
Nause and vomiting in end of life
Occurs in many patients Recommended levomepromazine May be another anti emetic If giving JRCALC drug seek advice from palliative care team
32
What is a palliative care emergency
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
33
What are reversible causes in end of life
``` Infection Hypercalcaemia Medication changes Treatment consequences Palliative emergencies ```
34
Palliative emergencies examples
``` Metastatic spinal cord compression(mssc) Superior vena cava compression Neutropenic sepsis Pathological fractures Seizures Hypoglycaemia Drug toxicity Pain crisis Resp crisis Anaphylaxis ```
35
What is metastatic spinal cord compression
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
36
Symptoms of metastatic spinal cord compression
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
37
What is radicular pain
Band pain round the body occurs in metastatic spinal cord compression
38
Late symptoms of metastatic spinal cord compression
Peri-anal numbness and lack of anal tone Not being able to open or control bladder or bowels Priapism
39
Management of metastatic spinal cord compression
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
40
What is superior vena cava compression
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
41
Signs and symptoms of superior vena cava compression
``` 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 ```
42
Management/ treatment options for Superior vena cava compression
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
43
What is neutropenic sepsis
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
44
Signs and symptoms of neutropenic sepsis
``` 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) ```
45
Management and treatment for neutropenic sepsis
Manage according to JRCALC guidelines | All should be transported to hospital
46
What is a respect form
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
47
Points to respect form
``` 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 ```
48
Key stages to the respect form
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
49
Relate respect form to other forms
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
50
Law and ethics of the respect form
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
51
What’s should look for on respect form
Personal preferences priorities 2 boxes for clinical recommendations only one signed if both act best interest Capacity Clinical signature - makes it valid

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