End of Life Care

Question 1

What is palliative care?

Answer 1

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

Question 2

What defines end of life?

Answer 2

• those likely to die within next 12 months
• those with advanced, progressive, incurable conditions
• general frailty
• those at risk of dying from sudden crisis of condition
• those with life threatening conditions caused by sudden catastrophic events

Question 3

What are the principles of good end of life care?

Answer 3

• open lines of communication
• anticipating care needs and encouraging discussion
• effective multidisciplinary team input
• symptom control
• preparing for death
• providing support for relatives before and after death

Question 4

What should be discussed as part of someones end of life care plan?

Answer 4

• their wishes/preferences/fears
• feelings/beliefs/values that can influence choices
• who should be involved in decision making?
• emergency interventions
• preferred place of care
• religious/spiritual/personal support
• advance and anticipatory care plan

Question 5

How can you formalise a patients preferences/wishes about their end of life care?

Answer 5

• advance statement (preferences)
• advance decision (refusals)
• power of attorney (allowing someone else to make medical decisions)

Question 6

Things to consider in assessing the validity of an advance decision

Answer 6

• is it clearly applicable?
• when was it made?
• did the patient have capacity when it was made?
• were they coerced into making it?
• has the decision been withdrawn?
• are there more recent actions/decisions inconsistent?

Question 7

What are the benefits of advance statements/decisions?

Answer 7

• enhances autonomy
• can improve discussions on end-of-life decisions
• avoid breaching patient’s personal/beliefs
• death with dignity

Question 8

What are the disadvantages of advance statements/decisions?

Answer 8

• 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

Question 9

What are the 5 priorities of care of dying people?

Answer 9

• possibility that a person may die within next few days/hours recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, which are regularly reviewed
• sensitive communication between staff and dying person and their close ones
• dying person and close people are involved in decisions about treatment to the extent that the dying person wants
• needs of close ones identified as important to the dying person actively explores, respected and met as far as possible
• an individual care plan including food, drink, symptom control, psychological/social/spiritual support is agreed, coordinated and delivered with compassion

Question 10

Recognition of death

Answer 10

• observe and confirmed for minimum of 5 minutes
• apnoea; no breath sounds

after 5 minutes:

• absence of pupillary responses to light
• absence of corneal reflexes
• absence of any motor response to supra-orbital pressure

Question 11

Confirmation of death

Answer 11

in primary care:

• absence of central pulse
• absence of heart sounds

in secondary care:

• asystole on a continuous ECG
• absence of pulsatile flow using direct intra-arterial pressure monitoring
• absence of contractile activity using echo