Palliative & EoL 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-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems and of physical, psychosocial and spiritual problems.

Question 2

What do we mean by end of life care?

Answer 2

Patients 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 co-existing 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 event

Question 3

What are the 7C’s of palliative care according to GSF?

Answer 3

• Communication
• Coordination
• Control of symptoms
• Continuity
• Continued learning
• Carer support
• Care of the dying

Question 4

Describe some example trajectories for the following life-limiting illnesses:

• ESRD
• Cancer
• Cardiac/resp failure
• Frailty

Answer 4

Question 5

Remind yourself of the clinical frailty scale

Answer 5

Question 6

What tool can be used to help identify people whose health is deteriorating?

Briefly describe this tool

Answer 6

SPICT (Supportive & Palliative Care Indicator Tool)

Helps to identify people with deteriorating health due to advanced conditions or a serious illness and prompts holistic assessment and future care planning.

**Be sure you can list a few indicators of general decline/deteriorating health

Question 7

Alongside the SPICT, Gold Standards Framework Prognostic Indicator can be used in primary care; briefly explain this guidance

*HINT: 3 parts

Answer 7

GSF is a UK based training primary care initiative to improve end of life care

Question 8

State some potential barriers to recognising deterioration

Answer 8

Question 9

Leadership Alliance for the Care of Dying People (LACDP) have identified 5 priorities for care of dying person; state these

Answer 9

Question 10

Why might a pt need palliative care input alongside active disease management?

Answer 10

• Help manage symptoms
• Plan ahead
• Help educate them about options available
• Help prepare pts & family for death

Question 11

State some factors that may indicate a pt is going to die imminently

Answer 11

Question 12

State some common symptoms experienced in people who are dying

Answer 12

• Pain
• Nausea & vomiting
• Breathlessness
• Restlessness & agitation
• Respiratory tract secretions “death rattle”
• Confusion
• Constipation
• Dry mouth/xerostomia
• Hiccups
• Itch
• Anorexia

Question 13

What do we mean by anticipatory prescribing?

Answer 13

Prescribe medications, to treat common/expected symptoms when dying, even when pt hasn’t got symptoms; enables prompt symptom relief at whatever time the patient develops distressing symptoms.

Question 14

Discuss the management of reduced food and fluid intake in pts who are dying

Answer 14

• Supported to eat & drink as long as they wish to do so
• Consider IV fluids/CAH (clinically assisted hydration); a lot to consider as more evidence is needed regarding whether it should be used in palliative care:
  
  • Must share uncertainty around whether CAH will prolong life or extend dying process
  • Discuss that it may relieve some symptoms
  • … but may also cause other problems
  • Regular mouth care must be given
  • Assess hydration status daily

The key question to answer is “will the treatment be of overall benefit to the pt”. You may not be sure of this answer and in this case you should start fluids and reassess/review… be sure to document this is what you are doing

Question 15

Discuss the management of N&V in pts who are dying

Answer 15

(See management of other symptoms for full info)

• Basic measures e.g. small frequent meals, avoid smell of food, acupressure bands…
• If underlying cause (e.g. electrolyte abnormality detected) correct
• Antiemetics
  
  • Different classes recommended based on cause
  • Levomepromazine is a good broad spectrum antiemetic and is the drug of choice in anticipatory prescribing for N&V

Summary from UHL Guidelines Palliative Prescribing

• Metabolic/drug induced: Haloperidol 500microgram - 1mg oral or via subcutaneous injection once to twice daily
• Raised ICP= cyclizine 50mg oral three times per day
• Gastric stasis= Metoclopramide 10mg oral three times per day
• Second line when haloperidol / cyclizine / metoclopramide have not worked, or where the cause of nausea and vomiting is unclear:
  
  • Levomepromazine 6.25mg oral or via subcutaneous injection once to twice daily

Question 16

Discuss the management of pain in pts who are dying

Answer 16

(See pain assessment & management FC for full details)

• Non-pharmacological: repositioning etc…
• WHO pain ladder
  
  • Opioid naïve: start at about 2.5mg - 5mg PO PRN up to hourly . If this controls pain, consider conversion to morphine sulphate modified-release (MR) twice daily. *Remember must also prescribe anti-emetic when prescribing opioid.

Image from UHL guidelines palliative prescribing

Question 17

Discuss the management of breathlessness in pts who are dying

Answer 17

• Non pharmacological: prone position, calm environment with reassuring professionals, reduce room temperature, cool flannel to face, open window, fan
• Trial of oxygen if sats <92%
• Consider if there is a reversible cause of breathlessness which can be treated (providing you think treatment is appropirate) e.g. chest infection, pulmonary emboli etc…
• Opioids (low dose)
  
  • Opioid naïve pts: SC morphine sulphate 2.5mg-5mg PRN up to hourly
  • Established on opioids: give ½ PRN dose for pain (e.g. 10mg PRN for pain, 5mg PRN for dyspnoea) OR consider increase in PRN dose by 30%
  • If effective can give modified release (up to 30mg for breathlessness)
• Anxiolytics
  
  • Lorazepam 500micrograms-1mg PO PRN, max 4mg/24hr
  • Midazolam 2.5-5mg SC PRN up to hourly

Question 18

Discuss the management of respiratory tract secretions in pts who are dying

Answer 18

• Non-pharmacological: position pt to allow gravity to move secretions, stop or reduce volume of IV/PEG feeds and/or IV/SC fluids
• Glycopyrronium 200micrograms SC PRN up to 2hrly (max dose 1.2mg/24hr)

Question 19

Discuss the management of restlessness & agitation in pts who are dying

Answer 19

• Non-pharmacological: try to find and resolve cause (e.g. uncontrolled pain, urinary retention, constipation, anxiety/fear etc…), family, calm environment, reduce number of people around, spiritual support, relaxation techniques
• When anguish & anxiety predominant: Midazolam 2.5mg-5mg SC PRN 1-2hrly
• When delirium & psychotic features prominent: Levomepromazine 6.25-12.5mg SC, 2-4hrly, max 50mg/24hr

**Occasionally combination of midazolam & levomepromazine required

Question 20

Discuss the management of delirium in patients who are dying

Answer 20

• Non-pharmacological: calm atmosphere, increased supervision, continuity with environment/routine/staff, ask family for advice, minimise distress, normal sleep-wake cycle, familiar objects, identify & treat any known causes
• Few pharmacological options:
  
  • In non-terminal phase: first choice Haloperidol (500micrograms PRN PO up to 2hrly, max 5mg/24hrs) or Lorazepam (500micrograms-1mg PO PRN max 4mg/24hr)
  • In last few days/hrs:
    
    • Midazolam 2.5-5mg SC PRN, 1-2hrly
    • Levomepromazine 6.25mg-12.5mg SC PRN, 2-4hrly max 50mg/24hr

Question 21

Discuss the management of cough in a dying patient

Answer 21

• Non-pharmacological: oral fluids e.g. honey & lemon in water, cough sweets, elevate head/sleep with pillows
• Codeine linctus 30-60mg PO QDS
• Oral morphine sulphate 2.5mg PO 4hrly

Question 22

Discuss the management of hiccups in a dying patient

Answer 22

• Chlorpromazine
• Others that may be used:
  
  • Haloperidol
  • Gabapentin
  • Dexamethasone (particularly if there are hepatic lesions)

Question 23

What drugs are prescribed as part of anticipatory prescribing in the dying? Include dose, frequency and route

*NEED TO KNOW, CAN BE ASKED IN EXAM

Answer 23

SUMMARY OF WHAT TO KNOW

• **Give all SC- ignore PO on opioids for pain*
• **If give 2 or more doses of any of them, consider syringe driver*

Question 24

Remind yourself of how to assess capacity as per MCA

Answer 24

Remember capacity is time and decision specific!!

Stage 1: is there an impairment or disturbance of the function of a person mind or brain: yes or no

Stage 2: is the impairment sufficient to constitute loss of capacity (four stages):

• Can they understand the information required to make the decision?
• Can they retain the information long enough to make a decision?
• Can they weigh up information?
• Can they communicate the decision back?

Question 25

Remind yourself what an advanced statement is

Answer 25

• Statement (written or verbal) of pts preferences, wishes and likely plans (e.g. preferred place of death)
• Not legally binding

Question 26

Remind yourself what an advanced decision to refuse treatment is

Answer 26

• Written statement of what the pt doesn’t want to happen to them which comes into force when capacity is lost
• Legally binding

The Mental Capacity Act 2005 makes clear that such advance directives are binding, unless the following exceptions apply:

• The decision has been subsequently withdrawn
• Power to make such decisions has been conferred to another person by creating a Lasting Power of Attorney
• Since making the will the patient has acted in a way that is clearly inconsistent with the advance decision remaining their fixed decision
• The person is not incapacitated and can decide for themselves
• The treatment in question is not that specified in the advance decision
• Any of the circumstances specified in the advance decision do not exist
• There ‘are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time of the advance decision and which would have affected his decision at the time of the advance decision.’

Question 27

Remind yourself what a lasting power of attorney is

Answer 27

Pt appoints an individual to make decisions on pt’s behalf should they lose capacity (can include decisions regarding medical care, refusing life sustaining treatment, moving to care home etc…)

Question 28

Discuss whether LPA can override advanced decisions

Answer 28

• Whichever was made most recently is the one that is valid
  
  • E.g. if you make an advanced decision prior to appointing an LPA then LPA can override it
  • E.g. if you make an advanced decision after appointing LPA then LPA cannot override it

Question 29

If as a doctor, you felt unsure about aspects of your patients care as they approached end of life, what guidance could you refer to?

Answer 29

GMC guidance regarding “Treatment & care towards the end of life”

This guidance provides you with a framework to support you in meeting the needs of your patient as they come towards the end of their life. It includes advice on topics such as:

• making decisions with patients who have capacity
• what to do if your patient doesn’t have capacity
• assessing the overall benefit of treatment
• advanced care planning
• meeting a patients’ nutrition and hydration needs
• cardiopulmonary resuscitation
• the role of relatives, partners and others close to the patient
• organ donation and care after death.

There is also a useful section on neonates, children and young people. It reminds you that decisions about treatment for these patients must always be in their best interests. And it provides advice about remaining sensitive to a parent’s concerns and help to resolve any disagreements.