Showing compassion and care of the dying Flashcards
How has the hospice movement evolved from its roots to modern day?
- Traditionally based in a ‘care home’ or hospice (as opposed to hospital)
- 80% care now outpatient/day care, in community and home care settings
What are the future challenges for the hospice movement?
- Hospices today already support 200,000 in UK
- Increasingly older population (cancer/other long term conditions)
- Projected double no. of people > 85 y/o in the next 20 years
What defines the hospice movement?
‘More than a clinical need’
- Social, spiritual needs as well as physiological/psychological
“There is so much more to be done”
How did the hospice movement shape palliative care?
- Improving QoL of patients and families alike facing a life-threatening illness
- Prevention and relief of suffering by:
• Early identification
•Assessment
• Treatment of pain
• Treatment of physical/psychosocial/spiritual needs
How did Dame Cicely Saunders re-shape pain relief?
- Previous practice in 50s/60s was to administer diamorphine (heroin) by injection only in ‘unbearable’ pain relief
- But became apparent that regular morphine PO provided better pain relief w/no more S/Es, w/no addiction
»> “Constant pain needs constant control”
What is holistic care?
- Considers person as a whole; physically, psychologically, socially and spiritually, in the management and prevention of disease
- Stemming from concept of link between between physical health and general ‘well-being’; virtuous circle based on trust, building rapport w/patient and family.
Why must patient pain be tackled?
Associated w/anxiety and depression
How do hospices channel holistic care in their setting?
- Hospices have warm furnishings, sympathetic lighting etc.
- ‘Home from home’
- No set ward rounds/visiting times
- Happy but tranquil environment
What is meant by the term, pharmaceutical care?
- Holistic approach; not just palliative medicine
- Legal, moral and professional responsibility; improving patient QoL, or preservation of QoL for as long as possible.
- “The responsible provision of drug therapy for the purpose of achieving definite outcomes that improve patient QoL”
What is medicines optimisation?
- Supporting safe, effective medicines use
- Not just focus on the medicines; support patient’s experience of taking evidence-based medicines safely
“Person behind the pills”
How are hospices funded?
- NHS (32%)
- Charities (68%)
- Privately run (some)
What are the examples of team-based services that hospices offer?
- Inpatient and respite care (giving carers a needed break)
- Outpatient and day care
- Hospital in-reach (inpatients; going into hospitals, recommendation for transfer to hospice etc)
- Community outreach
- Bereavement counselling
- Complementary therapy; aromatherapy, relaxation, Tai Chi etc.
- Research and education
> > > Offer choices of where patient wants to die.
How do charities contribute to the hospice movement?
- Charity shops
- Clinical care; provide support, information resources, counselling
- Funding grants
- Campaigns; policy and advocacy, “Dying matters” campaign etc.
- Education and research
- Specialist; improving care worldwide
What is “to palliate”?
- To relieve or lessen without curing; to mitigate or alleviate symptoms
»> Does not necessarily lead to end of life care.
Why is pain control important (in palliative care/general)?
Pain is patient’s greater fear (70%)
How is pain control achieved in palliative care?
- Pain ladder (stepwise approach; effective in 80-90% of cases), regular dosing etc.
- Drug, dose titration, formulation, route of administration, dose equivalence
- Opioid and chronic/specialist pain management, starting doses etc.
- Syringe drivers to mix compatible drugs (diamorphine used as more soluble than morphine)
How is symptoms management achieved in palliative care?
- Adjuvant drugs e.g. steroids (reduce swelling)
- Treating adverse effects e.g. constipation (give laxatives w/morphine)
- Dispel myths e.g. addiction
- Other symptoms e.g. secretions
What needs to be considered to ensure patient safety in palliative care?
• Prescribing
- Errors e.g. dose timing (MST is 12-hourly; not 8AM and 6PM as per ward round)
- De-prescribing drugs of no value (fewer the better; withdraw everything and reintroduce if needs be)
- Opioid doses, frequency, breakthrough pain
• Preparation
- Syringe drivers; compatibility
• Administration
- Syringe drivers (similar drivers etc.)
- Safe use of fentanyl TDD patches (heat induced OD)
• Information
- Warn patients about S/Es
- Safe disposal e.g. fentanyl patches; fold in half so irretrievable
How is syringe driver safety ensured?
- Syringe drivers composed of several complex medicines given together in a syringe SC
»> Not to be made up in patient’s kitchen by District Nurse (aseptic unit made-up, then picked up by DN etc.)
What was a common (but fatal) administration error w/syringe drivers?
- MS16 and MS26 mix-ups
- MS16 = mm/hr; MS26 = mm/24 hrs (former now withdrawn)
Define: anticipatory prescribing.
To enable prompt symptom relief at whatever time the patient, develops distressing symptoms; can be predicted and management measures put place in advance.
What are the issues with anticipatory prescribing?
- Problems w/accessing medicines out-of-hours causing distress, poor care
What medicines are used in anticipatory prescribing, and for what roles?
- Diamorphine injection; pain
- Midazolam; anxiety/restlessness
- Haloperidol; nausea/confusion
- Levomepromazine injection; N&V
- Hyoscine for SC; xs. respiratory secretions countering ‘death rattle’ - disconcerting for patients
How are anticipatory prescribed medicines supplied?
- Agreed drug list (enhanced services in some pharmacies)
- ‘Just in case’ boxes; for patients to keep at home
»> Abuse? Inappropriately administered?
What are the problems w/anticipatory prescribing?
- Misdiagnosing (symptoms, rate of deterioration)
- Inappropriate administration/disposal
What is the ‘Liverpool Care Pathway’, and how did it prove controversial?
- Good intent; best practice, consistency, supporting choice
- Evaluated best practice from hospice palliative medicine and transferred to general sector setting
»> Poor practice, lack of information and respect
»> Failure of proper communication
What did the LACDP conclude regarding the Liverpool Care Pathway and future strategies?
‘Once chance to get it right’ - Leadership Alliance for the Care of Dying People
- Shared decision-making and review
- Sensitive, honest, open communication
- Patient carer involved in decisions
- Needs of family respected
- Individualised patient care plan
What is the difference between sympathy and empathy?
Sympathy: feelings of pity and sorrow for someone else’s misfortune.
Empathy: ability to understand and SHARE the feelings of another; “put yourself in their shoes”
What are the 6 C’s of Care?
Care; that people should expect
Compassion; care delivered with
Competence; and expertise to deliver care
Communication; effectively w/patient and carers
Courage; doing the right thing
Commitment; stick with it, to improve care for patients
> > > Nursing principles applicable to all HCPs
What is the truly care for the patient?
- To listen to what a patient has to say and to understand them; not just give a reply
- Sense that HCP matters and that we can be trusted, building rapport w/patient
- Empathy, not sympathy
- 6 C’s
- Putting the patient first
#hello my name is campaign (HCPs more personable)
