Palliative care Flashcards
How many people die each year in England?
around 500,000
What is the definition of palliative care according to NHS England (2019)?
people who face progressive life-limiting illness, with or without comorbidities
What is the definition of palliative care according to Marie Curie (2018)?
palliative care is treatment, care and support for people with a life-limiting illness, and their family and friends
it’s sometimes called ‘supportive care’
What is the definition of end of life care according to the General Medical Council (2010)?
people are ‘approaching the end of life’ when they are likely to die within the next 12 months
this includes people whose death is imminent (expected within a few hours or days) and those with:
advanced, progressive, incurable conditions
general frailty and coexisting conditions that mean they are expected to die within 12 months
existing conditions if they are at risk of dying from a sudden acute crisis in their condition
life-threatening acute conditions caused by sudden catastrophic events
What is the definition of end of life care according to the Royal College of Nursing (2020)?
the term ‘end of life’ usually refers to the last year of life, although for some people this will be significantly shorter. the term palliative care is often used interchangeably with end of life care
however, palliative care largely relates to symptom management, rather than actual end of life care
Why is it difficult for people to talk about death?
fear, misunderstanding, previous experience
What are the NICE (2017) quality standards that indicate the care and support requirements for people approaching end of life (EOL)?
identified in a timely manner
communicated and offered information
offered a comprehensive holistic assessment
have their physical and psychological needs met
offered personalised support
offered spiritual and religious support
receive consistent care that is effectively coordinated
people who experience a crisis day or night receive appropriate care
people who would benefit from specialist support are offered this in a timely manner
What are the NICE (2017) quality standards that indicate the care and support requirements for families and carers approaching EOL?
offered a comprehensive holistic assessment in response to changing needs
What are the NICE (2017) quality standards that indicate the care and support requirements for patients and significant others after death?
the body of the deceased is cared for in a culturally sensitive manner
timely verification and receipt of death certificate
those affected by the death of someone are communicated in a sensitive manner and offered support
What are the NICE (2017) quality standards that indicate the requirements for health and social care professionals delivering end of life care?
have the knowledge, skills and attitude to deliver high-quality care and support
generalist and specialist services providing care for people approaching EOL have a multidisciplinary workforce sufficient in number and skill mix to provide high-quality care and support
What are the NICE (2017) quality standards that indicate the care and support requirements for patients and significant others in the last days of life?
adults are monitored for further changes to help determine if they are nearing death, stabilising or recovering
patients and significant others are given opportunities to discuss, develop and review an individualised care plan
patients who are likely to need symptom control are prescribed anticipatory medicines with individualised indications for use, dosage and route of administration
patients have their hydration status assessed daily and have a discussion about the risks and benefits of hydration options
Why is effective communication important in palliative care?
to establish a therapeutic relationship, trust and partnership
What are four types of barriers to effective communication?
patient ‘belief’
patient condition
environmental factors
practitioner factors
How can patient ‘belief’ contribute to poor communication?
previous experiences or personal attitudes cause patients to reframe message to fit their beliefs
How can patient condition contribute to poor communication?
message is not absorbed due to patients’ condition (e.g. effects of medication, dementia or hearing problems)
How can environmental factors contribute to poor communication?
noise or other external factors interfere with patients’ ability to receive message
How can practitioner factors contribute to poor communication?
nurses fail to communicate in a way patients can understand, or their body language gives patients an unintended message
What are four types of barriers to effective communication?
patient ‘belief’
patient condition
environmental factors
practitioner factors
How can patient ‘belief’ contribute to poor communication?
previous experiences or personal attitudes cause patients to reframe message to fit their beliefs
How can patient condition contribute to poor communication?
message is not absorbed due to patients’ condition (e.g. effects of medication, dementia or hearing problems)
How can environmental factors contribute to poor communication?
noise or other external factors interfere with patients’ ability to receive message
How can practitioner factors contribute to poor communication?
nurses fail to communicate in a way patients can understand, or their body language gives patients an unintended message
What is the Distress Thermometer?
a rating scale used to measure distress - 0 (no distress) to 10 (extreme distress)
allows a person to identify what they find upsetting, this can then be explored with a healthcare professional or other
What is the SAGE model?
Setting - If you notice concern - create some privacy - sit down
Ask - “Can I ask what you are concerned about?”
Gather - Gather all of the concerns - not just the first few
Empathy - Respond sensitively - “You have a lot on your mind”
What is the THYME model?
Talk - “Who do you have to talk to or to support you?”
Help - “How do they help?”
You - “What do YOU think would help?”
Me - “Is there something you would like ME to do?”
End - Summarise and close - “Can we leave it here?”
What does the SPIKES model for breaking bad news stand for?
Setting Perception Invitation Knowledge Emotion/Empathy Strategy/Summary
What happens in the ‘setting’ stage?
quiet environment
face the patient
mindful of others present
What happens in the ‘perception’ stage?
“What do you understand about X?”
What happens in the ‘invitation’ stage?
“Do you want me to give you the information now or later?”
What happens in the ‘knowledge’ stage?
warning shot
deliver the knowledge to the patient in a way that they can understand
What happens in the ‘emotion/empathy’ stage?
recognise emotional responses and act accordingly
What happens in the ‘strategy/summary’ stage?
check the patient’s understanding of the situation
ask if they have questions
thank the patient
What is advance care planning?
offers people the opportunity to plan their future care and support, including medical treatment, while they have the capacity to do so
allows those caring for the person to understand their wishes should they not have capacity
Capacity and consent are determined under which legislative frameworks and common case law?
Family Law Reform Act 1969 Children Act 1989 Mental Capacity Act 2005 Mental Health Act 1983; 2007 R (Tracey) v Cambridge University Hospital NHS Foundation Trust (2014)
What measures are provided by the Mental Capacity Act 2005 for people to plan their care and support in advance?
advance statements
lasting power of attorney (LPA)
advance decision to refuse treatment (ADRT)
What are advance statements?
not legally binding but should be considered carefully when future decisions are being made
they can include any information the person considers important to their health and care
What does ‘ReSPECT’ stand for?
Recommended Summary Plan for Emergency Care and Treatment
What is a ReSPECT form?
a national patient held document
completed following an advance care planning conversation between a patient and a healthcare professional
creates personalised recommendations for a person’s clinical care in a future emergency in which they lack capacity
provides health professionals with a summary of recommendations to help them to make immediate decisions about that person’s care and treatment
What is a Lasting Power of Attorney (LPA)?
involves giving one or more people legal authority to make decisions about health and welfare and/or property and finances
the nominated person(s) only makes decisions if the person lacks capacity
the registration process needs to be completed so that it is recorded at the Office of the Public Guardian
What is an advance decision to refuse treatment (ADRT)?
legally binding
a written statement of the wishes of the patient to refuse a specific medical treatment in a certain situation
only used if the person lacks capacity or the ability to make or communicate a decision
What are the two components of an ADRT?
(1) the treatment you would like to refuse
(2) the circumstances when you would like your ADRT to apply
this is then considered as to whether it is valid (accurately completed) and applicable (to the situation).
According to a systematic review by Kehl (2012), what are the four most reported signs and symptoms of dying?
dyspnoea (56.7%)
pain (52.4%)
respiratory secretions/death rattle (51.4%)
confusion (50.1%)
What is dyspnoea?
the difficulties a person experiences in their breathing pattern (inhaling and/or exhaling)
due to the location of primary cancer (main site), secondaries (metastases), or existing respiratory condition
the cause, location and severity will determine the intervention to reduce/resolve signs and symptoms
involves identifying and treating reversible causes of breathlessness (e.g. pulmonary oedema, pleural effusion)
What are non-pharmacological treatments for dyspnoea?
hand-held fan or opening a window to improve ventilation
enhance coping and functional ability using positioning, relaxation, controlled breathing (e.g. pursed-lip breathing) and anxiety management techniques, and by planning and pacing activities
cognitive behavioural approach
maintain activity levels
equipment, aids, and care package
breathlessness support service (e.g. pulmonary rehabilitation) depending on prognosis
What are the pharmacological treatments for dyspnoea?
oxygen therapy bronchodilators steroids benzodiazepines, OR/but possibly combined opioids
When is oxygen therapy considered?
offered to people known or clinically suspected to have symptomatic hypoxaemia
limited value if oxygen saturation is already >90% prior to starting oxygen therapy
How do you administer bronchodilators?
via inhaler, spacer or nebuliser
stopped if there is no benefit
When are steroids considered?
especially if previous therapy has been beneficial (e.g. for COPD)
When are benzodiazepines considered?
suggested as useful for people whose breathlessness is related to panic or anxiety attacks
e.g. lorazepam
When are opioids considered?
this may involve oral immediate action
most benefit for breathlessness at rest
e.g. Oramorph 2.5mg–5mg po PRN
What is the concept of understanding ‘total pain’?
developed by Cicely Saunders
pain extends the physical, and encompasses the psychological, social and also spiritual aspects of a person
List some examples of physical pain.
pain due to disease location
other symptoms (e.g. nausea)
physical decline and fatigue
List some examples of psychological pain.
grief, depression
anxiety, anger
adjustment to condition
List some examples of social pain.
relationships with family/carers
role in family
work life
financial problems
List some examples of spiritual pain.
existential issues
religious faith
meaning of life and illness
personal value as a human being
What are non-pharmacological treatments for pain?
assessment followed by appropriate interventions
psychological pain - offering and initiation of psychological support (talking therapy, distraction therapy)
spiritual pain - involvement of relevant religious leaders
What factors need to be considered before any analgesia is prescribed?
pain level (score, visual analogue) other details (OLDCARTS, SOCRATES, PQRST)
What does the OLDCARTS pain assessment stand for?
Onset Location Duration Character Alleviating and aggravating Radiation Time Severity
What does the SOCRATES pain assessment stand for?
Site Onset Character Radiation Associated symptoms Time/duration Exacerbating and relieving Severity
What does the PQRST pain assessment stand for?
Provoking Quality Region and radiation Severity Time
What happens after the pain assessment?
a decision is made as to the benefit of non-pharmacological interventions versus the benefits and risks of medication
if medication is deemed as clinically appropriate, past use of analgesia and the pain assessment will aid the determination of the type of pain relief
What is the World Health Organisation (WHO) analgesic ladder?
step 1 - non-opioid (e.g. paracetamol)
step 2 - weak opioid (e.g. codeine for mild to moderate pain + non-opioid)
step 3 - strong opioid (e.g. morphine for moderate to severe pain + non-opioid)
What happens in step 1?
prescribe non-opioids (e.g. paracetamol and NSAIDs)
if the pain level fails to improve or deteriorates this may lead to the next step
What happens in step 2?
weak opioids target different receptors compared to non-opioids
codeine may be used solely or combined with paracetamol
if the pain level fails to improve or deteriorates this may lead to the next step
What happens in step 3?
the use of stronger opioids is taken with caution (e.g. people who are opioid naive/have an existing respiratory condition)
first-line - immediate-release morphine (e.g. Oramorph)
maintenance stage - continue with immediate-release or change to a modified release (e.g. morphine sulphate); this would require a calculation due to the change in route
What are some alternative routes for delivering medication?
transdermal fentanyl patches
subcutaneous (e.g. syringe driver)
some medication requires specialist input (e.g. the prescribing of methadone in pain relief)
What is the McKinley syringe driver?
a portable, battery-operated device for delivering medication by continuous subcutaneous infusion
the preferred delivery of medication for symptom control or as part of end-of-life care
