End of Life Care

Question 1

Why is unexpected death not ideal?

Answer 1

Shock - no goodbyes
Accidents may mean multiple deaths - leading to press and legal involvement - distressing
Blame - especially in child deaths

Question 2

Define terminal care

Answer 2

close to death

Terminal care is the last phase of care when a patients condition is deteriorating and death is close.

Question 3

Define palliative care

Answer 3

care focused on quality of life
MDT
Communication is essential

Question 4

Where is most palliative care done?

Answer 4

primary care and specialist palliative acre facilities

Question 5

WHO palliative care statement (different from the goals - self titled as such)

Answer 5

Palliative care improves the quality of life of patients and families who face life- threatening illness, by providing pain and symptom relief, spiritual and psychosocial support… from diagnosis to the end of life and bereavement.

Question 6

What is the Scottish governments national action plan for palliative care called [2008]

Answer 6

Living and Dying well

Question 7

What is “Living and dying well”

Answer 7

the Scottish governments national action plan for palliative care [2008]
It states that…
palliative care is not just about care in the end of life
it is ensuring quality of life for patients and families at every stage of the disease Focuses on the person, not disease
Is holistic
Meets the physical, practical, functional, social, emotional and spiritual needs of patients and carers

Question 8

When does palliative care start

Answer 8

Early on in a disease as doctors we are encouraged to consider which of our patients would benefit from palliative planning and treatment from early on in their illness. This is a change in previous thinking of palliative care:

By identifying early which patients are likely to need palliative care we can discuss patient’s wishes with them and try where possible to care for them where they want to be treated and in a way that they want to be.

Question 9

How do you know a patient is ready for palliative care?

Answer 9

Using the ‘Supportive and Palliative Care Indicators Tool’
It is a guide for doctors to consider their patients who have a life-limiting diagnosis or a worsening chronic condition and highlight if they are at a stage where supportive and palliative care should take place.

Question 10

What is the first step in palliative care

Answer 10

Anticipatory care planning and being placed on the palliative care registar

Question 11

What questions should be asked in an anticipatory care plan

Answer 11

Where do they want to be cared for?
Do they want a DNACPR
Who do they want to be informed of their care and any changes in their condition? Are they fully aware of their prognosis?
Is their family aware of their prognosis?

Question 12

What is a palliative performance scale?

Answer 12

A scale with different functions by finding the best fit for your patient in each column you get a percentage which then associates with a prognosis

Question 13

What are the 3 types of disease trajectories

Answer 13

Slowly progressing then quick death - often malignancy
A variable trajectory following many very poorly episodes and episodes of feeling better - organ failure
Slow steady decline - frailty and dementia

Question 14

out with the GP practice who else needs to be notified about a palliative patient

Answer 14

Out of hours

Question 15

What symptoms should be controlled in palliative care

Answer 15

Any/all that bother the patient

Pain is often feared
Nausea, insomnia and anxiety often are upsetting for the patient

Question 16

WHO palliative care goals

Answer 16

Relief from pain and other distressing symptoms
Affirms life and regards dying as a normal process
Intends neither to hasten nor postpone death
Integrates the psychological and spiritual aspects of patient care
Offers a support system to help patients live as actively as possible until death
Offers a support system to help the family cope during the patients illness and in their own bereavement.
Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated.

Question 17

As well as out of hours and the practice team who else may be involved in palliative care

Answer 17

Macmillan Nurses, CLAN, Marie Curie Nurses

Religious or Cultural Groups amongst other support networks

Question 18

What factors may contribute to a “good death”

Answer 18

Pain- free death
Open acknowledgement of the imminence of death
Death at home surrounded by family and friends
An ‘aware’ death, in which personal conflicts and unfinished business are resolved
Death as personal growth
Death according to personal preference and in a manner that resonates with the person’s individuality

Question 19

What is the gold standard framework

Answer 19

The Gold Standards Framework offers tools to enable primary care to provide palliative care at home.

Question 20

Steps in breaking bad news

Answer 20

Listen
Set the Scene
Situation and Perception - Find out what the patient understands
Invitations - Find out how much the patient wants to know (warning shot here too)
Knowledge - Share information using a common language
Emotions
Strategy and Summary - Review and summarise
Allow opportunities for questions
Agree follow up and support

Question 21

Examples of emotions after bad news

Answer 21

Shock
Anger 
Denial
Bargaining
Relief 
Sadness
Fear
Guilt
Anxiety
Distress

Question 22

What is the process of grief like

Answer 22

Is a process that may take months or years

Patients may need to be reassured that they are normal

Abnormal or distorted reactions may need more help

Bereavement is associated with morbidity and mortality

Question 23

What percentage of people die in a hospice

Answer 23

15-20%

Question 24

What are the types of euthanasia

Answer 24

Voluntary Euthanasia – patients request

Non Voluntary Euthanasia – no request

Physician assisted suicide – Physician provides the means and the advice for suicide.

Question 25

How would you approach a patient looking for euthanasia

Answer 25

Listen
Acknowledge the issue
Explore the reasons for the request
Explore ways of giving more control to the patient
Look for treatable problems
Remember spiritual issues
Admit powerlessness