Living with Dying - Tutorial 5 Flashcards
Historically, in what setting did death normally occur in?
Institutional setting
What accounted for 1 in 3 deaths in the mid 19th century?
Infectious disease
What are the most common causes of death now?
Cancer and IHD
Since 1995 cancer has outstripped IHF
In the young, what percentage of deaths are accounted for by accidents?
38% of deaths in boys
23% of deaths in girls
What is the main cause of death in men aged 15-34?
Suicide
Since 1861, what has the life expectancy in Scotland increased by?
32.3 years for men and 34.1 years for women
What are the effects of unexpected death?
Causes a profound sense of shock, no chance to say goodbye or take back hasty words
Accidents might be compounded by multiple deaths, legal involvement or press coverage
Deaths of children carry an even more profound sense of shock e.g. SIDS has no definite diagnosis and may carry the stigma of parental blame
What is the last phase of care when a patient’s condition is deteriorating and death is close?
Terminal care
Often misleadingly only associated with cancer
What is a more helpful term for the management of conditions until the terminal phase is reached?
Palliative care
What is palliative care?
A philosophy of care that emphasises quality of life
Performed by a MDT - communication between members is essential
Where is most palliative care provided?
Most provided in primary care with support from specialist practitioners and specialist palliative care units (or hospices)
GPs can act as companions for patients undergoing palliative care
The WHO state that palliative care
improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spirit and psychosocial support.. from diagnosis to the end of life and bereavement
In 2008, the Scottish Government developed a national action plan for palliative and end of life care, what is this called?
Living and Dying Well
Living and Dying well states that “palliative care is not just about care in the last months, days and hours of a person’s life, but about
ensuring quality of life for both patients and families at every stage of the disease process from diagnosis onwards… palliative care focuses on the person, not the disease and applies a holistic approach to meeting the physical, practical, functional, social, emotional and spiritual needs of patients and carers facing progressive illness and bereavement”
What does palliative care encompass?
End of life care, regardless of cause of illness
What are doctors encouraged to do in relation to palliative care?
Consider which patients would benefit from palliative planning and treatment from early on in their illness
What are the benefits of identifying early which patients are likely to need palliative care?
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 treated
What is the ‘Supportive and Palliative Care Indicators Tool’?
A guide for doctors to consider their patients who have a life-limiting diagnosis e.g. cancer, or a worsening chronic condition e.g. COPD, and highlight if they are at a stage where supportive and palliative care should take place
What does supportive and palliative care start with?
Anticipatory care planning
What are some things to consider in supportive and palliative care planning?
Where does the patient want to be cared for
Does the patient want to be resuscitated in the event of a cardiac arrest or do they want to be allowed to die naturally
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
Once a patient has been diagnosed as at a palliative stage of care and these discussions have taken place, the patient should be placed on the practice’s palliative care register
What is done once the patient is on the palliative care register?
The plan for the patient should be sent to the out of hours service so that anyone who may be involved in the patient’s care is aware of the patient’s wishes
The practice will have regular palliative care meetings to discuss the patients on the palliative care register, with the MDT present, to ensure that everyone is aware of how the patient is
The patient will be reviewed regularly
What can be used to evaluate how quickly the situation is changing for the patient and to see if their care needs re-evaluated?
The Palliative Performance Scale
How are PPS scores determined?
By reading horizontally at each level to find a best fit for the patient who is then assigned as the PPS % score
What are some uses of PPS?
Excellent communication tool for quickly describing patient’s current functional level
May have value in criteria for workload assessment or other measurements and comparisons
Appears to have prognostic value
What are the benefits of palliative care in primary care?
Ensures practice have a register of palliative patients
Ensures that the team meet regularly to discuss the cases
Enhances communication between team members
Out of hours also notified of palliative cases
What are the features of managing symptoms in palliative care?
Pain is often feared by patients
No symptoms should be ignored
e.g. anxiety, insomnia and nausea may all be significant and distressing symptoms
It is important to respond globally to the patient and his or her family
According to the WHO, what are the features of palliative care?
Provides 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 patient’s illness and in their own bereavement
Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated
What are some professionals that might be involved in palliative care?
Primary care team Macmillan nurses CLAN Marie Curie nurses Religious or cultural groups
What have been described as elements of a good death in Western culture?
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 a personal growth - acceptance and moving on
Death according to personal preference and in a manner that resonates with the person’s individuality
Most people express the preference for a home death, what percentage of people achieve this?
26%
What framework offers tools to enable primary care to provide palliative care at home?
The Gold Standards Framework
These include setting up a cancer register, reviewing these patients and reflective practice
What are the stages of breaking bad news?
Listen Set the scene Find out what the patient understands Find out how much the patient wants to know Share information using a common language Review and summarise Allow opportunities for questions Agree follow up and support
What are the potential reactions to bad news?
Shock Anger Denial Bargaining Relief Sadness Fear Guilt Anxiety Distress
When is it useful to consider the stages of adjustment in grief, as described by Parkes?
When dealing with a bereavement and when a patient is given bad news or a life-limiting diagnosis
What are the features of grief?
Individual experience
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
What percentage of deaths occur in hospices?
15-20%
What is euthanasia?
Has come to mean the deliberate ending of a persons life with or without their request
What is voluntary euthanasia?
Patient’s request
What is non-voluntary euthanasia?
No request
What is physician assisted suicide?
Physician provides the means and the advice for suicide
Why do people request euthanasia?
3-8% of patients with advanced disease will ask to die
The most common reasons are unrelieved symptoms or the dread of further suffering
Some studies indicate that 60% of patients requesting euthanasia are depressed
How should you respond to a patient requesting euthanasia?
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
