Session 5. Frailty and End of Life Care

Question 1

define frailty

Answer 1

the clinically recognizable state of increased vulnerability resulting from ageing associated decline in reserve and function across multiple physiologic systems such that the ability to cope with everyday or acute stressors is compromised

• low grip strength
• low energy
• slowed walking speed
• low physical activity
• unintentional weight loss

Question 2

what are the indicators that can be used to detect frailty in patients/how can frailty be measured?

Answer 2

clinical frailty scale - https://www.researchgate.net/figure/Clinical-frailty-scale_fig2_323565633
Kaplan-Meier methods were used to estimate overall survival based on frailty status.

Question 3

describe some clinical consequences of frailty?

Answer 3

getriatric giants: immobility, independence, instability, incontinence, impaired memory, iatrogenesis

Question 5

how can frailty impact the management plan for the patient?

Answer 5

Seeing hearing and communication
Getting around
Looking after yourself
Housing and finances
Safety and relationships
Mental wellbeing
Staying healthy.
Once a person has been identified as frail, a holistic review by a general practitioner will allow for optimisation of the person’s health and for considered forward care planning. It may involve onward referral for a more Comprehensive Geriatric Assessment by an interdisciplinary team.

Comprehensive Geriatric Assessment (CGA) is the gold standard for the management of frailty in older people. It is a process of care known that involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health and has been demonstrated to be associated with improved outcomes in a variety of settings. Finally we look at whether frailty can be reversed.

Question 6

what are the challenges associated in achieving a ‘good death’?

Answer 6

• truthfulness with patients
• enabling informed consent
• allowing time to prepare
• avoiding isolation
• overcoming a wall of silence
• maintaining hope
• covid 19
• lack of time of healthcare professionals

Question 7

what services and interventions are available by hospices to patients with life limiting illnesses?

Answer 7

counselling
management of symptoms
leisure activities
spiritual care
either day care or all day and night management
family visits 
occupational therapist visuals

Question 8

define euthanasia

Answer 8

Euthanasia is the practice of intentionally ending life to relieve pain and sufferin

Question 9

what is the legal stance of euthanasia in the uk and specifically in the medical profession?

Answer 9

UK- NHS, GMC AND BMA = NO!

Other countries - belgium, netherlands and switzerland = YES

Question 10

list and discuss key ethical principles

Answer 10

Autonomy: If we consider the patient’s freedom of choice, we can argue that every individual has a right to choose and plan their own death, just as they have a right to decide what happens to their lives.
Beneficence: Euthanasia can be seen as doing good by ending the patient’s suffering and providing him or her with peace of mind and dignity in dying.
Non-maleficence: Medical professionals are bound by ethical duty to “do no harm”. Performing euthanasia is a violation of this basic principle.
Justice:
Some people may feel that euthanasia is a reasonable and beneficial regulation of limited resources within a particular society. Since patients who are extremely sick are likely to die soon anyway, it would be much more utilitarian to divert resources towards saving other patients who have a higher chance of surviving and contributing back to society, rather than wasting resources on life-sustaining care.
However, this viewpoint can also be seen as inhumane and uncompassionate. It threatens to erode the basis of a caring society. Therefore, the issue of euthanasia is really more about moral decisions than resource allocation.

Question 11

what is the doctrine of double effect?

Answer 11

The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end. According to the principle of double effect, sometimes it is permissible to cause a harm as a side effect (or “double effect”) of bringing about a good result even though it would not be permissible to cause such a harm as a means to bringing about the same good end.
eg: morphine - used for symptom relief but can also cause death of individual earlier due to respiratory depression

Question 12

why is a drug review so important?

Answer 12

Antimuscarinics in cognitive impairment.
Long acting benzodiazepines and some sulphonylureas, other sedatives and hypnotics increase falls risk.
Some opiate based analgesics increase risk of confusion or delirium.
NSAID can cause severe symptomatic renal impairment in frailty.