End of Life Care

Question 1

Define palliative care

Answer 1

Looking after people with incurable illnesses, relieving their suffering and supporting them through difficult times

Question 2

What is involved in palliative care?

Answer 2

• relieves pain and other distressing symptoms
• affirms life and regards dying as a normal process
• intends neither to hasten nor postpone death
• integrates psychological and spiritual aspects of patient care
• MDT approach
• will enhance QoL and may positively influence the course of the illness
• is applicable early in the course of the illness, in conjunction with other therapies that are intended to prolong life, such as chemo and includes investigations needed to better understand and manage distressing clinical complications

Question 3

Define supportive care

Answer 3

care that helps the patient and their family to cope with their condition and its treatment from pre-diagnosis, through the process of diagnosis and treatment, to cure, continuing illness or death and into bereavement

Question 4

Define end of life care

Answer 4

enables the supportive and palliative are needs of both patient and family to be identified and met throughout the last page of the life and into bereavement. It includes the management of pain and other symptoms and the provision of psychological, social, spiritual and practical support

Question 5

What is the holistic approach to palliative care?

Answer 5

There is not just physical support.

It includes psychological, spiritual and social health

Question 6

What is total pain?

Answer 6

Palliative care emphasises the need to relieve pain in the four areas of holistic care:

• physical - can worsen psychological ones e.g. pain can lead to depression
• emotional - anxiety and depression can worsen many symptoms e.g. pain and breathlessness
• social - lack of income, loss of carers, affects physical symptoms
• spiritual - issues affect psychological wellbeing

Question 7

What is the difference between the old and better concept of trajectories at the end of life?

Answer 7

Old concept
- Palliative care starts once curative care has finished. they are separate
Better concept
- Supportive/palliative care can start at diagnosis and becomes an increased proportion of the care a patient receives as the disease progresses. It also includes bereavement care for those left behind

Question 8

What are the four profiles of death?

Which are becoming more common?

Answer 8

1. Sudden death - high QoL, sudden decline
2. Terminal illness - high QoL, steady decline
3. Organ failure - peaks and troughs
4. Frailty - gradual decline at low QoL

Question 9

What are the two trajectories of end of life within the emergency department?

Answer 9

Spectacular
- usually a RTC
- care is prioritised
- attention is high
- palliative care needs are met e.g. pain relief 
Subtacular 
- ranked low in terms of staff and support
- often neglected
- elderly with long term conditions

Question 10

What was the EURECA study?

What was its aim?

Answer 10

Exploring, understanding and reducing emergency cancer admissions
To understand the decision making process and patients’ experiences of the time leading up to admission, the admission process and the immediate period following admission

Question 11

Explain why sometimes positive experience of emergency admission can turn to concerns over care at the ward level.

Answer 11

• priotised, 4 hour window, seen to quickly
  At ward level
• lack of attention (staffing issues?)
• poor communication
• lack of recognition of expert family/patient
• lack of continuity of care

Question 12

What is meant by attention and therapeutic presence?

Answer 12

Just the presence of health care professionals can be therapeutic in itself. It reassures patients that someone is looking out for them and is properly overseeing their care

Question 13

Give 3 examples of end of life care policies

Answer 13

Gold standards framework
Liverpool care pathway
Preferred priorities of care

Question 14

What is covered in the end of life care strategy (2008)?

What are its aims?

Answer 14

• covers all conditions
• covers all care settings (e.g. home, hospice, care home, community hospital, prison etc)
• has been developed within the current legal framework
  Aims
• to bring about a step change in the quality of care for people approaching the end of life
• to enhance choice at the end of life
• to deliver the Government’s manifesto commitment to double investment in palliative care

Question 15

What are the stages of disease and dying?

At what point of this pathway can the three policies be implemented?

Answer 15

Advancing disease GSF, PPC
Increasing morbidity
Last days of life LCP
First days of death
Bereavement

Question 16

How was the Liverpool Care Pathway viewed?
What is needed for it to be successful?
What recommendations were made by the 2013 review?

Answer 16

• Positive view of the pathway in some, poor use in others - Needed leadership, education, cross boundary communication, recognition/early diagnosis
  Recommendations
• phasing out, replacing with individual care plans
• should only be placed on LCP by a senior responsible clinician in consultation with healthcare team
• decision to withdraw care should not be taken ‘out of hours’
• an urgent call of Nursing and Midwifery Council to issue guidance on end of life care
• an end to incentive payments
• a new system-wide approach to improving quality of care for the dying

Question 17

What are the 3 triggers that suggest a patient is nearing the end of their life?

Answer 17

1. The surprise question ‘Would you be surprised if this patient were to die in next few months, weeks, days’
2. General indicators of decline - deterioration, increasing need or choice for no further active care
3. Specific clinical indicators related to certain conditions

Question 18

What are the two aspects of advance care planning?

Answer 18

Advanced statement
- formalise what patients and their family do wish to happen to them
- can be useful to clinicians in planning on patient’s individual care
- not legally binding and may also need advanced direrct and DNAR
ADRT (advanced decision to refuse treatment)
- formalises what patients do not wish to happen to them
- legally binding document
- related to capacity of decision making, Mental capacity act, living will etc.