S5 L1 Palliative care - A good death

Question 1

What are the key objectives of palliative care?

Answer 1

• Affirm life but regard dying as a normal process
• Provide relief from pain and other distressing symptoms
• Neither hasten or postpone death
• Integrate psychological and spiritual aspects into mainstream patient care
• Provide support to enable patients to live actively as possible until death
• Offer support to the family during the patient’s illness and in their bereavement

Question 2

How does the WHO define palliative care?

Answer 2

An approach the improves the quality of life of individuals and their families facing problems 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, pychocosocial and spiritual

Question 3

Is there such thing as a good death?

Answer 3

• No one wants to die so how can it be a good thing
• Improve the QoL of people that are going to die - reaching the end of their life
• Part of caring is helping people have a good death

Question 4

How do you facilitate a good death in the dying?

Answer 4

• Remember that suffering is experience by people, NOT bodies
• More than symptom control
• Care involves the physical, psychological, emotional, social and spiritual aspects → Holistic approach

Question 5

Why is death so difficult for practitioners and patient?

Answer 5

• Own death is unimaginable

- No one believes they’re going to die!

Question 6

What factors make a good death difficult?

Answer 6

• Truthfulness (honest/open) with patients
• Enabling informed consent
• Allowing time to prepare
• Avoiding isolation
• Overcoming a wall of silence
• Maintaining hope by accompanying them on the journey (it is so important what you say to patients)

Question 7

What is the dilemma around dying?

Answer 7

How do you diagnose when someone is dying?

At which point can you say they are dying

Question 8

What is futility?

Answer 8

Where curative treatment is continued where there is no prospect of success- prolongation of life
- enabling someone to have a good death is not a failure, continuing treatment that will not work can prevent a patient from having a good death

Question 9

Why is holistic care important?

Answer 9

Need to treat the patient as a whole
Symptoms control is important but other non-drug aspects of life are also important
People can experience pain associated with other things - spiritual reasons, family reasons, social reasons
Patients may need to confess/sort things out so that they can have a good death
Resolving conflicts can help release pain

Question 10

What is anticipatory grief?

Answer 10

Psychological process that a patient (and relative) go through when they are dying 
- Anger
- Denial 
- Bargaining 
- Depression 
- Acceptance (or resignation) 
Can go through them in any order 
Before the patient dies

Question 11

How can you facilitate a good death?

Answer 11

• Avoid medicalisation and prolonging the dying process
• Avoid the situation of ‘medical captivity’ of being a frightened patient, enable their release from captivity
• An agreed care plan is required avoiding ‘managed states’ (ReSPECT form/DNAR)
• Ability to die one’s own death
• Adequate symptoms control

Question 12

Who is the informal carer and why are they important?

Answer 12

• Family, loved one, friends, carers etc.
• Look after the patient the most
• A lot of support and input is required for these patients
• Opportunities for respite care maybe important
• Grief before or after death
• Ensure they do not feel guilty that they have ‘failed’ their loved one in any way - reassure they did their best

Question 13

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Answer 13

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Question 14

What if the patient is suffering?

Answer 14

Suffer = inadequate palliative care
Require urgent review by a specialist
Euthanasia is not a prevision of good dying but a failure of good communication and palliative care

Question 15

What is the doctrine of double effect?

Answer 15

Some medication help to relieved pain and suffering can then bring forward death
Foreseen but unintended consequence

Question 16

What are the principles of a good death?

Answer 16

• To be warned when death is coming and learn what can be expected
• To be abele to retain control of what happens
• To be able to afford dignity and privacy
• To have control over pain relief and other symptoms control
• To have choice and control over where death occurs )(at home or elsewhere)
• To have access to information and expertise of whatever kind is necessary
• To have access to any spiritual or emotional support required
• To have access to hospice care
• To have control over who is present and who shares the end
• Able to write an advance directives which ensure wishes are respected
• Have time to say goodbye, and control over other aspects of timing
• To be able to leave when it is time to go, and not to have life prolonged pointlessly

Question 17

What are hospices?

Answer 17

• Style of care, rather than a place
• Includes team of people - Drs, Nurses, Social workers, therapists, counsellors, trained volunteers
• For the patient and their families
  Offers
  → Primary care → medical interventions to help alleviate and manage a patients symptoms
  → Spiritual and emotional support
  → Assistance with practical matters such as insurance
  → Offer respite care- carers a break
  → Bereavement care

Question 18

Define euthanasia?

Answer 18

The painless killing of a patient suffering from an incurable and painful disease or in an irreversible coma
Active→ deliberate use of lethal substance to end someone’s life
Passive→ withholding of life support and life sustaining treatments
Voluntary→ performed with patient full and informed consent
Non voluntary→ patient is unconscious or incapable of making a decision - someone decided on patients behalf
(assisted suicide- similar but undertaken by the patients themselves but Dr may have prescribed the treatment)

Question 19

What is the law around euthanasia in the UK?

Answer 19

Illegal → considered murder or manslaughter

Question 20

What are the ethical principles around euthanasia?

Answer 20

Arguments for and against
For
→ More humane than allowing someone to suffer continuous pain
→ Dying with dignity is important
→ Human right
→ Autonomy
→ QoL can only be assessed by individual themself
Against
→ Difficult to regulate
→ People vulnerable to abuse - could be used as murder in some cases - family member act in ‘best interest’
→ Goes against Hippocratic Oath - Do no harm
→ Determining mental capacity and competence can be difficult
→ Patients may feel like a burden on family so do it for the wrong reasons - pressurised to end their own life
→ People might regret decision- made at bad moment in life
→ Culture, religions and societies - Affront the sanctity of life

Question 21

What are ReSPECT forms?

Answer 21

Recommended Summary Plan for Emergency Care and Treatment

• Creates personalised recommendations for person’s clinical care and treatment in a future emergency in which they are unable to make or express choices
• Usually created in people who have complex health needs, people nearing end of life, risk of sudden deterioration or cardiac arrest
• Non-legally binding
• Reviewed and adapted if circumstances change
• Created through conversations between a person, their families, and their health and care professionals to understand what matters to them and what is realistic in terms of care and treatment
• Allows people to have a good death