End of Life Care

Question 1

What is end of life?

Answer 1

may be 12 months before death - it is a period when a patient is living with and impaired by a fatal condition.

Question 2

Major illness that cause death have a pattern - what are some we often see in healthcare?

Answer 2

Cancer trajectory - functioning well for some time then deteriorate rapidly
Organ failure - moderate function couple with partial recovery
Dementia/frailty - low baseline deteriorating over time

Question 3

What are the top 5 causes of death?

Answer 3

1. Coronary artery disease
2. Dementia and AD
3. CVD
4. Lung cancer
5. COPD

Question 4

How can you respond to the ‘am I going to die?’ question?

Answer 4

Novice - you could be, we are working to treat… can I call someone to come in to be here with you and we can discuss it some more?

Able - are you feeling worried about dying? what has been going on?

acknowledge fear
don’t avoid the word die

Question 5

How to respond to tough questions?

Answer 5

with more questions - create a conversation.

every patient is different
can’t fix illness

Question 6

What is a tool you can use to trigger to identify end of life care?

Answer 6

SPICT tool

• bed >50% of the day
• dependent on others for care needs
• 2 or more unplanned admissions in 6mths
• significant weight loss 5-10% over 3-6mths
• persistent symptoms
• patient requests supportive care or treatment withdrawal

or more simply
‘would you be surprised if this patient died in the next 12 mths?’

Question 7

What are some responses you could use early in the disease trajectory?

Answer 7

would you like to discuss the future now? or where to from here?

Can you tell me what you understand is happening?

Question 8

What are some strategies to tough conversations?

Answer 8

Introduce
Sit with uncertainty
Respond to questions
show concern and name distress - accept patient as expert

Discussing prognosis

• admit mistake
• chronic disease, can’t make it go away
• uncertain - what is important to you/your family

are you the kind of person who wants to know what will happen in the future?

Question 9

What are goals of care?

Answer 9

agreed and shared goals that shape the health care of a patient

• what matters
• change over time
• all types of care (nutrition, hydration, values)

Question 10

How can you manage a goals of care discussion?

Answer 10

REMAP

• reframe
• expect emotion
• map for the future
• align with the patients values
• plan medical treatments that match values

Conflicts happen
- specialists wanting to continue

Question 11

How to direct a family meeting?

Answer 11

1. Introduce and set goals
   - introduce each person
   - summarise goals and confirm these
   - build a relationship. Can you tell us about the things you liked prior to getting sick
2. Determine what the family knows
3. The medical review - bring them up to date
4. Silence -

Question 12

how to deal with conflict?

Answer 12

1. Notice the conflict
2. Prepare yourself
3. Find a non-judgemental starting point
4. Reframe emotionally charged issues
5. Respond empathetically
6. Look for options to meet both parties needs
7. If no satisfactory agreement can be reached, get help

Question 13

How do you manage medication at end of life?

Answer 13

What is the role of medications

• current symptoms or longer term conditions.
• withdrawal? can you replace with subcut option