End of life care

Question 1

How is the end of life defined?

Answer 1

likely to die within the next 12 months (incl. those whose death is imminent)

Question 2

What does end of life care involve?

Answer 2

1. recognise dying
2. management of pain and other symptoms
3. provision of psychological, social, spiritual and practical support - addresses concerns and distresses
4. addresses needs of both pt and family and continues through to and including after death and bereavement
5. advance planning of care including place of death and pre-emptive prescribing
6. simplifying medications
7. education of the pt and family about what will happen

Question 3

What doe we mean by the surprise question?

Answer 3

For patients with advanced disease or progressive life limiting conditions –Would you be surprised if the patient were to die in the next few months, weeks or days?

Question 4

What is the factor that most influences whether a pt is likely to die in the next few months, weeks or days?

Answer 4

fragility - are they in a fragile enough condition that relatively minor worsening could result in the end of their life

Question 5

What would you do if a pt’s answer to the surprise question was no?

Answer 5

optimise symptoms and quality of life
plan for the future
communicate the assessment to the pt

Question 6

What does advance care planning involve?

Answer 6

discussion with the pt AND the family about their wishes and thoughts about the future - what is important to them?
allow the pt to choose their place and manner of death
must involve patients and their families/loved ones/nominated others and it isn’t a one-off discussion

Question 7

Cana pt demand DNACPR if it is not clinically indicated?

Answer 7

No

Question 8

Should DNACPR be given when it may be futile?

Answer 8

No as offering medical futile treatments is unethical and against the GMC

Question 9

What should be done before DNA CPR is documented in the notes?

Answer 9

Need to speak to the pt and their family and make a note of the discussion that was had in the notes and the decision made

Question 10

Is stopping antibiotics, fluids and treatment etc a form of DNACPR?

Answer 10

no

Question 11

How can we recognise dying?

Answer 11

1. what has changed in the last few weeks/hours/days?
2. Has their level of function changed for the worse?
3. Is there evidence of progressive and irreversible organ failure?
4. Have relevant treatment/interventions been effective?
5. Has the pt/relevant others seen a decline or think that they are dying?
6. Are any of the above reversible?

Question 12

what is the death rattle?

Answer 12

when people are too weak to clear their secretions, it tends to rattle around at the back of their throat

Question 13

What symptoms can the end of life team address?

Answer 13

  Pain
  Breathlessness
  Unable to drink or eat
  Nausea and vomiting
  Agitation/confusion
  Respiratory secretions (death rattle)
  Dry mouth
  Other discomforts

Question 14

what is pre-emptive/anticipatory prescribing?

Answer 14

Prescription of drugs which may be needed for symptom management in dying phase
the symptoms may not be present yet

Question 15

is reduced oral intake normal for sb who is dying?

Answer 15

Yes

Question 16

What forms of distress may the pt have?

Answer 16

 Psychosocial distress
 Fear, anger, sadness, regrets
 Previous problems with family, social circumstances
 Existential distress
 Spiritual issues
 Depression
 Family members distress causes pt distress

Question 17

what kinds of medicines may be put through a syringe driver?

Answer 17

anaelgesia
anxiolytic
antiemetic
buscopan for XS resp secretions

Question 18

What matters to pts at the end of life?

Answer 18

their symptoms are managed 
choice 
dignity - treated as an individual
QoL
preparation - practical and personal 
support for carers/family
co-ordination and continuity

Question 19

What are the steps that are taken to prepare an pt and their family for death?

Answer 19

1. education of the family about what to expect
2. ensure medications are available - pre-emptive prescribing
3. find out where is the preferred place to be cared for

Question 20

How is death verified?

Answer 20

 No heart sounds or carotid pulse for one minute
 No breath sounds or respiratory effort for one minute
 No response to painful stimuli
 Pupils are fixed and dilated

Question 21

What do relatives need to be able to register the death with the registrar of births, deaths and marriages?

Answer 21

medical cause of death certificate

Question 22

How many doctors need to complete a cremation form and who are they?

Answer 22

2

one who has seen the pt alive and another who never met the pt before (independent)

Question 23

What help is offered to the bereaved?

Answer 23

can come back to discuss any events again with a member of staff
counselling
referral to GP
Specialist bereavement psychology support