End of Life Care Flashcards
WHO definition of palliative 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 the combination of approaches in the new concept of palliative care
disease modifying or potentially curative
supportive and palliative care
bereavement care
when is someone ‘approaching the end of life’
likely to die within the next 12 months
who are those facing imminent death and those with the following
– 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
people who require palliative conditions
The concept of palliative care should not be linked only to malignant disease
Manynon-cancer diseases require palliation of symptoms
– E.g. Motor Neurone disease / End-stage Cardiac failure / End- stage COPD / Advanced renal disease etc.
what are the palliative care aims
- whole person holistic approach
- focus on quality of life, including good symptom control
- care encompassing the person with the life-threatening illness and those that matter to them
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 palliative 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 specialise palliative care
Based on the same principles of palliative care, but can help people with more complex palliative care needs
Complementary Therapies
music
gentle touch
pet
aromatherapy
Psycho-spiritual distress
can further exacerbate your physical symptoms and is multifactorial, consider the following:
– Uncontrolled physical symptoms
– Alcohol / drug withdrawal
– Depression
– Other medical causes e.g. hyperthyroidism
Key themes for development
- early identification of patient who may need pallative care
- advance/anticipatory care planning (including decisions regarding cardiopulmonary resuscitation (DNACPR)
Advance & 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 should be discussed with a patient in regards to palliative care
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
Advance & Anticipatory Care Plan
“A dynamic record that should be developed over time through an evolving conversation, collaborative interactions and shared decision making. It is a summary of “thinking ahead” discussions between the
person, those close to them and the practitioner”
Advance Statement
A “statement that sets down your preferences, wishes,
beliefs and values regarding your future care”
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 are the three things required for the formalisation of wishes
advance statement
advance decision
power of attorney
Advance Statements
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
Advance Decision
Advance refusal of treatment / Advance directive / “ADRT” / ”Living Will”
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
Advance Decision- How do I know it’s 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?
two mental capacity acts
‘Mental Capacity’ Act, 2005( England and Wales)
‘Adults withIn capacity ’Act (Scotland), 2000
pros of the advance decision
Enhances autonomy
May encourage / improve discussions on end-of-life decisions
Avoid breaching patient’s personal / religious beliefs
Death with dignity
cons of advance decision
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
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”:
who is the GSF for
– For people considered to be at any stage in the final years of life; – For people with any condition or diagnosis
– For people in any setting, in whichever bed they are in
– Provided by anyone in health or social care
– At any time needed
what is the first principle in care for people in the last days sonf hours of life
nformative, 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
Recognition of death
• After five minutes of continued cardiorespiratory arrest confirm:
absence of pupillary responses to light
absence of the corneal reflexes
absence of any motor response to supra-orbital pressure
Recognition of death in primary care
absence of mechanical cardiac function is normally confirmed by:
Absence of a central pulse
Absence of heart sounds
Recognition of death 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
Support for families
– Chaplain
– Counsellors
– Family workers
– Health care professionals
Pain ladder
• By mouth
The oral route is preferred for all steps of the pain ladder
• By the clock
Cancer pain is continuous - analgesics should be given at
regular intervals, not on demand
• Adjuvants
To help calm fears and anxiety, adjuvant drugs may be
added at any step of the ladder”
