End of Life Care

Question 1

WHO definition of 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 is the combination of approaches in the new concept of palliative care

Answer 2

disease modifying or potentially curative

supportive and palliative care

bereavement care

Question 3

when is someone ‘approaching the end of life’

Answer 3

likely to die within the next 12 months

Question 4

who are those facing imminent death and those with the following

Answer 4

– 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

Question 5

people who require palliative conditions

Answer 5

 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.

Question 6

what are the palliative care aims

Answer 6

• 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

Question 7

what are the principles of good end of life care

Answer 7

 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

Question 8

what is generalist palliative care

Answer 8

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

Question 9

what is specialise palliative care

Answer 9

Based on the same principles of palliative care, but can help people with more complex palliative care needs

Question 10

Complementary Therapies

Answer 10

music
gentle touch
pet
aromatherapy

Question 11

Psycho-spiritual distress

Answer 11

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

Question 12

Key themes for development

Answer 12

• early identification of patient who may need pallative care
• advance/anticipatory care planning (including decisions regarding cardiopulmonary resuscitation (DNACPR)

Question 13

Advance & Anticipatory care planning

Answer 13

‘…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’

Question 14

What should be discussed with a patient in regards to palliative care

Answer 14

 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

Question 15

Advance & Anticipatory Care Plan

Answer 15

“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”

Question 16

Advance Statement

Answer 16

A “statement that sets down your preferences, wishes,

beliefs and values regarding your future care”

Question 17

Advance Decision

Answer 17

– 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”

Question 18

what are the three things required for the formalisation of wishes

Answer 18

advance statement
advance decision
power of attorney

Question 19

Advance Statements

Answer 19

 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

Question 20

Advance Decision

Answer 20

 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

Question 21

Advance Decision- How do I know it’s valid?

Answer 21

 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?

Question 22

two mental capacity acts

Answer 22

 ‘Mental Capacity’ Act, 2005( England and Wales)

 ‘Adults withIn capacity ’Act (Scotland), 2000

Question 23

pros of the advance decision

Answer 23

 Enhances autonomy
 May encourage / improve discussions on end-of-life decisions
 Avoid breaching patient’s personal / religious beliefs
 Death with dignity

Question 24

cons of advance decision

Answer 24

 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 25

Gold Standards Framework (GSF)

Answer 25

“Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by generalist frontline care providers”:

Question 26

who is the GSF for

Answer 26

– 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

Question 27

what is the first principle in care for people in the last days sonf hours of life

Answer 27

nformative, timely and sensitive communication is an essential component of each individual person’s care

Question 28

Principle 2:

Answer 28

Significant decisions about a person’s care, including diagnosing dying, are made on the basis of multi- disciplinary discussion

Question 29

Principle 3:

Answer 29

Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed as far as is possible

Question 30

Principle 4:

Answer 30

Consideration is given to the wellbeing of relatives or carers attending the person

Question 31

Recognition of death

Answer 31

• 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

Question 32

Recognition of death in primary care

Answer 32

absence of mechanical cardiac function is normally confirmed by:
 Absence of a central pulse
 Absence of heart sounds

Question 33

Recognition of death in hospital

Answer 33

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

Question 34

 Support for families

Answer 34

– Chaplain
– Counsellors
– Family workers
– Health care professionals

Question 35

Pain ladder

Answer 35

• 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”