End of Life Care Flashcards
What is pallative care?
Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual
What is meant by the term ‘approaching the end of life’?
likely to die within the next 12 months
What defines those facing imminent death?
- Advanced, progressive, incurable conditions
- General frailty (likely to die in 12 months)
- At risk of dying from sudden crisis of condition
- Life threatening conditions caused by sudden catastrophic events
Other examples of when pallative care should be applied that is not malignant disease
- Motor neuron disease
- end-stage cardiac failure
- COPD
- advanced renal disease
What are the main aims of palliative care?
- HOLLISTIC - whole person approach
- focus on QOL and symptom control
- person and family included
What are the principles of good end of life care?
- Open lines of communication
- Anticipating care needs and encouraging discussion
- Effective multidisciplinary team input
- Symptom control – physical and psycho-spiritual
- Preparing for death - patient & family
- Providing support for relatives both before and after death
What is generalist pallative care?
Integral part of the routine care delivered by all health and social care professionals to those living with a progressive and incurable disease, whether at home, in a care home, or in hospital
What is specialist palliative care?
Based on the same principles of palliative care, but can help people with more complex palliative care needs
What are common physical symptoms associated with a requirement for palliative care control?
- Pain
- Dyspnoea
- Nausea / vomiting
- Anorexia / weight loss
- Constipation
- Fatigue
- Cough
What can psycho-spiritual distress cause?
exacerbation of physical symptoms with no physiological explanation
What is advance and anticipatory care planning?
‘…an ongoing process of discussion between the patient, those close to them and their care providers,focusing on that person’s wishes and preferences for their future. It is perhaps best defined as an umbrella term potentially covering a number of component planning processes, legal, personal and clinical’
What can be included in advance and anticipatory care planning?
- Wishes / preferences / fears about care
- Feelings/ beliefs / values that may influence future choices
- Who should be involved in decision making?
- Emergency interventions e.g. CPR
- Preferred place of care
- Religious / spiritual / other personal support
- May wish to make an Advance & Anticipatory care plan / formalise wishes regarding care
What are the 3 main ways to formalise wishes?
- advance statement
- advance decision
- power of attorney
What is an advance statement?
A “statement that sets down your preferences, wishes, beliefs and values regarding your future care”
What is an advance decision?
A “decision you can make now to refuse specific treatments in the future”
- Terms used include ‘Advance Decision to Refuse Treatment’ (ADRT) / ‘Advance Directive’, “Advance refusal of treatment”, “Living Will”
What is the main objective of an advance statement?
- Setting down preferences, wishes, beliefs and values regarding future care
- Aim to provide guidance if patient loses capacity to make decisions or to communicate them
- Informs about patient’s wishes
- Request will be given weight
- BUT…future decisions can’t be bound by their statement
- Treatment must be of overall benefit to the patient
What are the objectives of an advance decision?
- Decision to refuse a specific type of treatment at some time in the future
- Makes a patient’s wishes known if unable to make or communicate decisions
- May be issues around life sustaining treatment (e.g. ventilation / resuscitation status (DNACPR) etc.)
- Validity and applicability need to be considered
How do you know if an advance decision is valid?
- Is it clearly applicable?
- When was it made?
- Did the patient have capacity when it was made?
- Was it an informed decision?
- Were there any undue influences when made?
- Has the decision been withdrawn?
- Are more recent actions / decisions inconsistent?
What laws cover advance directives?
- ‘Mental Capacity’ Act, 2005 (England and Wales) – Specific sections within Act covering ADRT
- ‘Adults with Incapacity’ Act (Scotland), 2000
- No specific framework for Advance Decisions in Scotland, but must comply with the Act
- In determining what, if any, intervention is to be made, account shall be taken of past and present wishes and feelings of the adult
Pros of advance directives
- Enhances autonomy
- May encourage / improve discussions on end-of-life decisions
- Avoid breaching patient’s personal / religious beliefs
- Death with dignity
Cons of advance directives
- May not be valid
- May not be applicable
- Attitudes may change with onset of serious illness
- May have been advances in medicine since being made
What is the Gold Standards Framework (GSF)?
“Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by generalist frontline care providers”
5 priorities for care or dying people
- The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.
- Sensitive communication takes place between staff and the dying person, and those identified as important to them.
- The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.
- The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.
- An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.
Principles of care for people in the last days and hours of life
- Principle 1: Informative, timely and sensitive communication is an essential component of each individual person’s care
- Principle 2: Significant decisions about a person’s care, including diagnosing dying, are made on the basis of multi- disciplinary discussion
- Principle 3: Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed as far as is possible
- Principle 4: Consideration is given to the wellbeing of relatives or carers attending the person
When is some said to be dead?
“The simultaneous and irreversible onset of apnoea and unconsciousness in the absence of the circulation“
What is the criteria needed to be fulfilled so someone to be pronounced dead? In different settings
In primary care absence of mechanical cardiac function is normally confirmed by:
- Absence of a central pulse
- Absence of heart sounds
In hospital can be supplemented by one or more of:
- Asystole on a continuous ECG
- Absence of pulsatile flow using direct intra-arterial pressure monitoring
- Absence of contractile activity using echo
What should be confirmed after 5 mins of continued cardiorespiratory arrest?
- absence of pupillary responses to light
- absence of the corneal reflexes
- absence of any motor response to supra-orbital pressure
