End Of Life Flashcards
Liverpool care pathway
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Perception that hydration and some medication may have been withheld or withdrawn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
Ambitions for palliative and end of life care 2015-2020
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
Leadership alliance for the care of dying people 2014
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
Department of health - our commitment to you and end of life care 2016
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
NICE guidelines (NG31) - care of dying adult
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
The route to success in end of life care - achieving quality in ambulance service 2012 GSF
- 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)
7 C’s to gold standard framework
Communication Coordination Control of symptoms Continuity of Care Continued learning Cared support Care in the dying phase
3 step process to GSF
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
What is palliative care
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
What is end of life
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
End of life vs palliative care
Palliative Care aims to decrease suffering with a condition, end of life is comfort care provided to those facing the end of their life
Signs of end of life patient
Cold peripheries Altered breathing Temperature Confusion Incontinence Restlessness Congestion Reduced urine output Increased sleep
Behaviours for end of life
Pre planning Saying goodbye Communication change Hallucinations Behavioural changes
1-3 months signs and symptoms of end of life
Reduced appetite
Decreased fluid tolerance
Social withdrawal
Prolonged periods of rest and immobility
1-2 weeks signs and symptoms end of life
Increased sleep Restlessness Increased confusion Hallucinations Physiological changes Complete intolerance for food Breathing more congested
1-7 days
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
Last minutes of life signs and symptoms
Patient no longer able to respond
Breathing pattern becomes gasping
Aims of palliative care
- 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
6 questions to ask end of life patient
- What is understanding of illness
- Are you receiving or due to receive any medical treatment ?
- Is there documentation/ other services involved?
- Would you want to manage at home
- What local services are available?
- What do we need to do next / tomorrow ?
What is anticipatory prescribing ?
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
Dyspnoea in end of life
Severely impacted quality of life, often psychological. Discomfort may vary and may not be associated with hypoxia, tachypnea or Bradypnea
Listen to patient description
Non-pharmacological management for dyspnoea
Positioning
Airflow - use fan or window
Relaxation, distraction, reassurance
Controller breathing technique
Pharmacological treatment for dyspnoea
Opioids
Sensitivity of the respiratory centre to stimulation by carbon dioxide is reduced by morphine
Resp centre is area rich with opioid receptors
Paramedic options
Oral, sc or IM morphine
Safety net ensure review by gp, district nurse, ooh, palliative care team
Anticipatory medication
Out of hours gp review
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
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
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
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
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
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
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
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
What are reversible causes in end of life
Infection Hypercalcaemia Medication changes Treatment consequences Palliative emergencies
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
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
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
What is radicular pain
Band pain round the body occurs in metastatic spinal cord compression
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
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
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
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
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
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
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)
Management and treatment for neutropenic sepsis
Manage according to JRCALC guidelines
All should be transported to hospital
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
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
Key stages to the respect form
- Understand - establish a shared understanding of the person state of Health and medical conditions
- Set goals - to establish what is important to the person and what they see as main focus of their treatment
- Plan - to discuss treatments that should be considered as well as treatments which they may not want or may not help
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
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
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
