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 the trends in patient characteristics for in hospital cardiac arrests?
Out of Hospital Cardiac Arrests
Mean age 64
what is the difference between euthanasia and assisted suicide?
- Euthanasia is the act of deliberately ending a person’s life to relieve suffering, e.g. a doctor administering a lethal cocktail of drugs explicitly to end a life
- Assisted suicide is the act of deliberately assisting or encouraging another person to kill themselves
- Physician assisted suicide involves prescribing lethal drugs intended explicitly to end a life. The person takes the mediations themselves or is assisted in some way to take them
