Station renal, palliative

Question 1

What medication would you be most appropriate for confusion at end of life?

Answer 1

Underlying causes of confusion need to be looked for and treated as appropriate, for example hypercalcaemia, infection, urinary retention and medication. If specific treatments fail then the following may be tried:

• first choice: haloperidol
• other options: chlorpromazine, levomepromazine

In the terminal phase of the illness then agitation or restlessness is best treated with midazolam

Question 2

Why would it not be appropriate for patient to die at home

Answer 2

Patient preference to stay in hospital or carere distress

Not having a good support system

Distressing symptoms needing hospital support

Question 3

What are the causes confusion at end of life?

Answer 3

frality,polypharmcy,infections,brain metastasis,delirum

Question 4

What to expect once dialysis has stopped?

Answer 4

Without dialysis, toxins build up in the blood, causing a condition called uremia. The patient will receive whatever medicines are necessary to manage symptoms of uremia and other medical conditions. Depending on how quickly the toxins build up, death usually follows anywhere from a few days to several weeks.

As the toxins build up, a person may experience certain physical and emotional changes. In the final days, the body starts to shut down. In most instances, the shut-down is an orderly series of physical changes which may include:

• Loss of appetite and fluid overload
• Sleeping most of the day
• Restlessness
• Visions of people who don’t exist
• Disorientation, confusion and failure to recognize familiar faces
• Changes in breathing Congestion Changes in color and skin temperature

Patients who choose to stop or not start dialysis are not required to eat or take in fluids. In most cases, a patient is allowed to eat or drink if they want to, but forcing fluids or nutrition is not recommended.

Medicines can be given for pain, anxiety, agitation or congestion. . As the body’s systems shut down, a person slips into unconsciousness and the heart stops beating.

Most people who pass away from kidney failure have what family members and caregivers describe as a “good death.” A study reported that patients who discontinued dialysis described a good death as pain-free, peaceful and brief. The patients’ families echoed this sentiment, adding a good death included having loved ones present at the end.

Question 5

Who are the palliative healthcare providers?

Answer 5

Interrelated professionals from various disciplines such as :

Doctors
Nurses
Social workers
Pharmacist
Dietitian
Massage therapist
Others

Question 6

What are the services provided under palliative care?

Answer 6

Multisectoral team including nursing , medical, social , counselling , home health aide etc.

Counselling services for bereavement

Dietary counselling

Physical therapy
Occupational therapy

Speech therapy

Investigations and drugs

Durable medical equipments and supplies

Question 7

What are the different categories of support in palliative care?

Answer 7

1. Pain management
2. Symptom management : gastrointestinal , weakness,fatigue, urogenital issues, delirium , shortness of breath etc
3. Spiritual and emotional support

Question 8

How can pain be managed?

Answer 8

Common suffering in palliative care

Not all pains respond equally to opioid

Pain may not be directly related to tumour , other co- morbids such as arthritis , pressure sores etc can add on to the suffering

Psychological distress can present as physical pain or increase pain perception

Biological : From cancer , drugs , surgery , radiotherapy , therapeutic intervention

Social – financial issues , lack of independence , family difficulties

Psychological – fear or death , dislike being in hospital , difficulty accepting diagnosis and/or delay in diagnosis , depression etc

First step : Careful assessment and diagnosis of cause
Second step : Drugs according to the analgaesic ladder
Third step : If pain persist – addition of co- analgaesic drugs , oncological or anaesthetic intervention
Fourth step : If pain persist – Specialist palliative care intervention

Mild pain : Non- opioid eg Paracetamol +/- adjuvant

Moderate pain : Simple analgaesic eg paracetamol + weak opioid eg tramadol , codeine , dihydrocodeine

Severe pain : Strong opioids eg diamorphine , morphine +/- non-opioid +/- adjuvant

Question 9

What adjuvant drugs can be used for pain?

Answer 9

NSAIDS – eg Celecoxib , diclofenac etc for bone pain and inflammatory pain
Anticonvulsants eg Carbamazepine, gabapentin, pregabalin etc for neuropathic pain
Tricyclic antidepressant eg amitriptyline for neuropathic pain and depression
Biphosphonate eg disodium pamidronate for metastatic bone disease
Dexamethasone for headache from cerebral oedema due to brain tumour

Morphine :
Should be given regularly by mouth
If a patient need additional doses to the regular doses , then the amount could be included in the following day regular dose until the requirement is stable ( this is referred to as “titration”
Once stable daily dose requirement is established , the morphine can be changed to sustain released preparation

If more than 2 prn doses in 24 hours , increase regular dose of morphine by 30 to 50 percent every 2 to 3 days

Stop increasing the dose when pain is relieved or intolerable side effects

Breakthrough dose should be 1/6 of 24 hour dose

Question 10

What to if the pain is uncontrolled?

Answer 10

Morphine :
Should be given regularly by mouth
If a patient need additional doses to the regular doses , then the amount could be included in the following day regular dose until the requirement is stable ( this is referred to as “titration”
Once stable daily dose requirement is established , the morphine can be changed to sustain released preparation

If more than 2 prn doses in 24 hours , increase regular dose of morphine by 30 to 50 percent every 2 to 3 days

Stop increasing the dose when pain is relieved or intolerable side effects

Breakthrough dose should be 1/6 of 24 hour dose

Change to sustained release preparation
If for example a patient is comfortable on 20 mg morphine elixir 4 hourly

20 mg morphine elixir 4 hourly = 120 mg per day

Therefore patient can be prescribed 60 mg twice daily of a 12 hour preparation

Or 120 mg daily of a 24 hour preparation

Question 11

What needs to be considered when giving analgesia?

Answer 11

Patient size
Renal function
Already on weak opioid
Consider alternative opioid such as fentanyl if worried of morphine metabolite accumulation
Parenteral route for patients who cannot take orally
Patients needing continuous analgesia – subcutaneous infusion is preferable

Nausea/vomiting : can be managed or prevented using anti-emetics such as metoclopramide , domperidone
Some can be given mixed with diamorphine though precipitation occur at high doses eg cyclizine, metoclopramide, haloperidol
Constipation is very common – treated and/or anticipated with lactulose ,senna or co-danthramer
Confusion, persistent and undue drowsiness , myoclonus , nightmares and hallucinations suggest opioid toxicity

Could be due to :

Over-rapid dose escalation which usually respond to dose reduction and re-titration

May be due to poorly opioid responsive pain and may need adjuvant

Antipsychotic can be given while waiting for resolution. Some patient may tolerate alternative opioid eg oxycodone better

Question 12

How can gastro intestinal symptoms be managed?

Answer 12

Anorexia , weight loss , malaise and weakness :

Due to cancer- cachexia syndrome mediated through chronic stimulation of acute phase response and tumour substances secretion

Calorie-protein support and parenteral feeding of limited benefit

Management is largely supportive

gastric distension
May be treated with :

Antacid and/or antiflatulent

Eg simeticone and domperidone 10 mg three times a day

Persistent hiccups can be treated with metoclopramide

bowel obstruction
Metoclopramide should be avoided in complete bowel obstruction , in which case antispasmodic is preferred eg hyoscine butylbromide
(60 -120 mg in 24 hours – usually given as thrice daily dose )
Octreotide may be given to dry up gut secretions (to reduce volume of vomit)
Defunctioning colostomy or venting gastrotomy
Lower bowel obstruction may resolve with stent insertion or transrectal resection of tumour
Steroid may shorten obstruction episode if resolution is possible

Question 13

How can nausea and vomiting be managed?

Answer 13

Common especially if opioid given without anti-emetic

Anti-emetic example :
Haloperidol 1.5 mg once or twice daily
Metoclopramide 10-20 mg three times a day
5HT3 antagonist eg ondansetron 8 mg orally or slow iv if risk of nausea and vomiting is high
Cyclizine may also be used

Question 14

How can respiratory symptoms be managed?

Answer 14

Breatlessness is very distressing
Reversible conditions should be treated eg pleural effusion ,heart failure or chronic pulmonary disease
Panic breathlessness cycle : pacing, prioritising , breathing training , anxiety management , hand held fan etc
Oxygen use with careful consideration
Benzodiazepines eg lorazepam (sublingual for rapid absorption
Troublesome unproductive cough : codeine or morphine elixir for it’s antitussive effect (avoid methadone because long duration of action )
Excessive respiratory secretion : Hyoscine hydrobromide 400 to 600 micrograms every 4 to 8 hours (take note the difference with hyoscine butylbromide)
Glycopyrronium subcutaneous infusion of 0.6 to 1.2 mg in 24 hours may also be used

Question 15

How can other physical symptoms be managed?

Answer 15

Directly by tumour eg hemiplegia

Indirectly eg bleeding or venous thromboembolism due to coagulation disturbances

Complications of treatment eg lymphoedema after breast surgery

Reversal of reversible factors and involvement of multidisciplinary team

Question 16

How can non-physical symptoms be managed?

Answer 16

Depression is very common in a life limiting and/or life disabling context

Often missed and dismissed

May respond to drug and/or non-drug modality

Question 17

What non drug treatment can offered at end of life?

Answer 17

Pain :

Consider guided imagery , relaxation , hypnosis, art/pet/play therapy ,acupuncture , biofeedback, massage , heat/cold,yoga,TENS, distractions

dyspnea
Suction of secretions

Positioning, loose clothes, fan

Limit iv fluids

Breathing exercises, guided imagery , relaxation , music

fatigue
Sleep hygiene

Gentle exercise

Address other factors such as : Anaemia , depression , side effects of medications

Nausea and vomiting
Consider bland , soft food , adjust timing and volume of food

Aromatherapy

Address constipation – increase fibres in diet and encourage fluids

oral lesions/dysphagia
Oral hygiene

Liquid , solid and oral medication chosen appropriately

Treat infections and complications eg mucositis, pharyngitis

Oropharyngeal motility study and speech (feeding team) consultation

pruritus
Moisturise skin

Try specialised anti-itch lotions

Apply cold packs

Counter stimulation , distraction , relaxation

Question 18

What is hospice care?

Answer 18

Hospice refers to a philosophy of care that strive to support dignified dying with a good death experience for those with terminal illness

It entails a joint work between interdisciplinary teams of professional and volunteers who provide medical , psychlogical and spiritual support for the patients and family

Usually in their final weeks or months of life
How do palliative care and hospice differ?
The main difference between palliative and hospice care is when they’re available.

Palliative care is available from the moment of diagnosis. In other words, it doesn’t depend on the stage of your illness or whether you’re still receiving curative or life-prolonging treatments.

The table below explains some key differences between palliative and hospice care.

Palliative Care Hospice
Who’s eligible? anyone with a serious, long-term illness, regardless of the stage anyone with a terminal illness whose doctor determines they have less than 6 months to live
What does it involve? • symptom relief
• help making important medical and treatment decisions
• emotional, spiritual, and financial support for the patient and their family
• assistance in coordinating care • symptom relief
• help making important end-of-life decisions
• emotional, spiritual, and financial support for the patient and their family
• assistance in coordinating care
Can you still get curative treatments? yes, if you wish no, you must stop curative treatments in order to qualify for hospice
Can you still get life-prolonging treatments? yes, if you wish no, you must stop life-prolonging treatments in order to qualify for hospice
Who’s involved? a doctor or nurse(s) specializing in palliative care, as well as other healthcare professionals such as your primary doctor, pharmacists, social workers, and counselors a doctor or nurse(s) specializing in hospice care, as well as other healthcare professionals such as your primary doctor, pharmacists, social workers, and counselors
Where is it available ? depending on where you live, home care is sometimes available but is most often offered through a hospital or outpatient clinic • a hospital
• a nursing home
• an assisted-living facility
• a hospice facility
• your own home
How long can you get it for? depends on your insurance coverage and what treatments you need as long as you meet the care provider’s life expectancy requirements
When can you get it? as soon as you receive a diagnosis when an illness is terminal or life-limiting
Hospice is only available toward the end of life. It can be an option when a cure is no longer possible or you decide to forego further life-prolonging treatment.

Question 19

What prognostic tools can be used?

Answer 19

Prognostic tools:
– General/elderly (eg Gagne, Lee, Suemoto)
– Specific (non malignant) disease
• COPD
• Heart failure
• Liver disease
• Dementia

Malignancy
– Malignancy symptom specific
– Modified Glasgow Prognostic Score (mGPS)
Functional
– Karnofsky score
– ECOG (Eastern Cooperative Oncology Group)
• Disease/function combined
– Prognosis in Palliative care study (PiPs
PiiP

Question 20

What are the trajectories of decline?

Answer 20

Sudden death: 14%
• Organ failure: 19%
• Malignant disease: 21%
• Frailty/dementia: 42%

Question 21

What are the 4 dimensions of dying?

Answer 21

Physical
psychological
social
spiritual

Question 22

What are the stages of bereavement?

Answer 22

Denial
• Anger
• Bargaining
• Depression
• Acceptance

extended cabler ross
Shock
• Denial
• Anger
• Bargaining
• Grief/depression/guilt
• Testing
• Acceptance

but more complicated
Modified by individual’s psychological makeup 
Mdifid bi
• Influenced by context
• Not necessarily a linear sequence
– Some get stuck in one mode
– Some cycle through the modes

Question 23

What is discussed in advanced care planning?

Answer 23

Advanced care planning 
d pl
(Exploring options)
What do you want?
(Statement of wishes and 
t f ih
What don’t you want?
(ADRT/DNAR+AND)
Who do you want to speak 
yt 
(LPOA/Proxy 
(LPOA/Py

Question 24

What are some general indicators of decline?

Answer 24

Decreasing activity and increasing dependence
• General physical decline
• Repeated unplanned admissions
Advanced life shortening disease
Decreasing response to treatments
Patient choice of no further active treatment
progressive wiegt loss
repeated unplanned admissions
sentinel events(serious falls, bereavement)
• Albumin<25g/l
felt eligible for DS1500

Question 25

What are some supportive and palliative care indicators tool?

Answer 25

If two of:
– Performance status poor (spends 50% day in 
Pf
– Two or more unplanned admissions
– Weight loss (5-10% in 3/12 or BMI<20)
– Persistant symptoms despite treatment
– Lives in NH or needs care at home
– Patient requests palliative care/withdrawal of 
Ptit t

Disease specific

Cancer
• Functional ability deteriorating

• Too frail for oncology treatment

Respiratory disease

• SOB at rest or on minimal

– Needs LTOT
– Previous need for ventilation

– Ventilation contraindicated
– (Development of Right HF)

Heart disease
– CHF NYHA stage 3 or 4 or 
CHF NYHA t3 4 
ttbl
• SOB/chest pain at rest on or 
minimal exertion
– Severe inoperable PVD

Neurological disease
• Progressive deterioration
in physical and cognitive function despite optimal treatment
• Speech problems with
increasing difficulty communicating and progressive dysphagia
• Recurrent aspiration ;
breathlessness or respiratory failure

Kidney disease
Stage 4 or 5 CKD with 
St4 5 CKD it
• Kidney failure complicated with 
• Stopping dialysis

Dementia/Frailty
• Unable to dress walk or eat 
Ubltd
• Choosing to eat and drink less; 
• Urinary and faecal incontinence
• No longer able to communicate 

• Fracture femur: multiple falls
• Recurrent febrile episodes or infections; aspiration pneumonia

Question 26

What are the signs of diagnosis?

Answer 26

Some combination of:
• Patient bedbound
• Poor oral intake
– at most taking sips of water
– unable to take oral medication
• Impaired level of consciousness
• Evidence of peripheral circulatory shut down
• Disordered breathing pattern (eg Cheyne
Didd bthi

Potential reversible causes excluded:
– Infection
– Dehydration/biochemical disorder
– Drug toxicity
– Treatable organ failure
– Acute intracranial event 
– Depression
– Delirium
• …or treatment likely to be ineffective or futile/ 
ttt likltb
• …or declined

Question 27

What should the patient care plan include?

Answer 27

Patient care plan
Guidance/pathways:
• Gold Standards Framework-developed in community setting
• LCP (Liverpool Care pathway)-now discarded
Care individualised to include:
• Patients preferences
• Remembering all the 4 dimensions
• Review of treatment/stopping inappropriate interventions
– Medication/medical intervention (DNAR/?iv fluids)
– Nursing intervention (but not nursing care!)
• Prescription of medication for symptom control
• with anticipatory prescribing
• in a form the patient that can be given ( S/C possibly
ifth

Question 28

What are the ethical principles?

Answer 28

Ethical principles
– Autonomy, non-maleficiance, beneficence, justice
• Presumption in favour of prolonging life
– Decisions must not be motivated by a desire to
Diit
– Avoidance of burdensome/futile intervention
– When a patient is perceived as in a terminal state
Whtit iid itil tt
thhld t bbjtd tttt
thi

Question 29

How can capacity be assessed?

Answer 29

The Mental Capacity Act (MCA) 2005 is a piece of legislation that applies to 16-17 year olds and adults (those 18 years old and over) who lack capacity to make decisions about their care/treatment when that decision needs to be made. Lack of capacity may be temporary (e.g. induced by drugs or alcohol) or permanent (e.g. a cognitive impairment). The MCA is designed to protect vulnerable individuals who lack this capacity, ensuring the decisions made in their care involve them as much as possible and are done in their best interests.

Mental Capacity Act (MCA) 2005 key principles

Five key principles underpin the MCA.

Capacity is assumed; it needs to be proven otherwise
Enabling people to make their own decisions
Unwise decisions
Best interests
Less restrictive option
Capacity is Assumed; It Needs to be Proven Otherwise

This means that you must assume that every adult has the capacity to make his or her own decisions, unless proven otherwise. Just because someone has a particular medical condition or disability does not mean you can assume lack of capacity. In this situation, the onus is to prove that this person does not have capacity.

Enabling People to Make Their Own Decisions

This means that an individual must be helped and supported, as much as possible, to make a decision for themselves. If after all practicable help and support, a lack of capacity is established, it is still important to involve the individual in the decision-making process as much as possible.

Unwise Decisions

People may make decisions that you consider to be unwise; this does not mean that you can treat them as lacking capacity simply because of this. Every individual will have different priorities, morals, and feelings, and will therefore make different decisions.

Best Interests

If a person lacks capacity, anything done for them or on their behalf must be done in their best interests.

Less Restrictive Option

If someone without capacity is having a decision made for them, the people making the decision should be careful to ensure they take the least restrictive option, minimising interference with the person’s rights and freedom.

There are four criteria used when assessing capacity in adults.

The individual must be able to understand the information relating to the decision
The individual must be able to retain that information
The individual must be able to weigh up the information and reach a conclusion
The individual must be able to communicate the decision they have made.
Ways to Meet the Criteria

Help and support can be provided in order to enable an individual to meet the above assessment criteria. For example, using simple language in order to explain the information, or allowing someone to communicate their decision in a number of ways (in writing, verbally, in sign-language, or their normal form of communication, etc.)

Mental Capacity Act

If an individual is not able to do any of the above four criteria, then the Mental Capacity Act (MCA) will assess them and therefore treat them as lacking capacity for that specific decision in question.

Fluctuating Capacity

It is important to note here that capacity is not absolute. Sometimes, an individual’s capacity can fluctuate (e.g. someone with dementia). Or in other circumstances, someone will have the capacity to make a decision on something simple but not something more complex. It is therefore always important to assess whether individuals have the capacity to make a specific decision at that time.

Question 30

What other documents can be used for advanced care planning

Answer 30

The Mental Capacity Act (MCA) includes provisions that allow people to plan for their care in advance, for a situation in the future where they do not have the capacity to make decisions. Two of these are Advanced Statements and Advanced Decisions. An individual can make both an Advanced Statement and an Advance Decision.

Definition of Advanced Decisions

An Advanced Decision, short for Advanced Decision to Refuse Treatment, is a legally binding document. Its purpose is to ensure that an individual can refuse a specific treatment(s) that they do not want to have in the future.

Advanced Decision Criteria

In order for an Advanced Decision to be legally binding, it must meet certain criteria:

​ It must be valid (this means it must have been made at a time when the individual had capacity to make that decision).

​ It must be applicable (this means the wording must be specific to the medical circumstances, and not vague or unclear).

​ It must have been made when the individual was over 18, and fully informed about their decision.

​ It must not have been made under the influence or duress of other people

​ It must be written down, be signed and witnessed (if it concerns a refusal of life-saving treatment)

What Can Advanced Decisions Cover?

Treatments that can be refused include life-sustaining treatments. It cannot refuse basic care (such as washing), food or drink by mouth, measures designed purely for comfort (e.g. painkillers), or treatment for a mental health condition if the individual is sectioned under the Mental Health Act. It can also not demand specific treatment or something that is illegal (e.g. assisted dying).

Definition of Advanced Statement

An Advance Statement is sometimes called a “Statement of Wishes and Care Preferences”. It allows an individual to make general statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment.

An Advance Statement is not by itself legally binding, but legally must be taken into consideration when making a “best interests” decision on someone’s behalf under the Mental Capacity Act (MCA), 2005. This is because one of the criteria of the MCA is that a patient’s “wishes, feelings, beliefs and values” must be taken into consideration; an Advanced Statement provides evidence of this.

Advanced Statement information included

Information that can be included in an Advanced Statement can be anything that is important to the individual. This might include:

​ Religious or spiritual views, and those that might relate to care

​ Food preferences

​ Information about your daily routine
​ Where you would like to be cared for (in hospital, at home, in a care home etc.)

​ Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)

What Can Advanced Statement Cover?

An Advanced Statement can be made verbally, but it is better to write it down so there is clear documented evidence of an individual’s wishes and views. Copies of the Advanced Statement can be given to anyone the individual wishes to have a copy (e.g. their GP, carers and relatives).

Built in to the Mental Capacity Act (2005) are provisions designed to aid decision making on behalf of vulnerable individuals who lack capacity. Three of them are making a Lasting Power of Attorney, Independent Mental Capacity Advocates, and the Court of Protection. Each have different roles but all aim to ensure that all decisions made on behalf of an individual are in their best interests.

Lasting Power of Attorney (LPA)

If an individual wants to legally appoint someone they trust to make decisions on their behalf in the future if they lose capacity, they can do this by making a lasting power of attorney (LPA). Usually an individual chooses a close relative or friend to be their “attorney”, who is given legal power to make decisions about their health and care if they lose capacity at some point in the future.

An individual’s attorney can make decisions about health and care decisions, including:

Where an individual should live, what care or treatment they should receive, decisions about their daily routine (food, activities, etc.). If special permission has been given, an attorney can also make decisions about life-saving treatment.

Independent Mental Capacity Advocates (IMCAs)

IMCAs are used when an individual lacks the capacity to make a specific important decision, when there is no-one independent of services (e.g. a family member or friend) appropriate to represent the individual lacking capacity.

IMCAs support and represent the individual who lacks capacity, ensuring the Mental Capacity Act, 2005 is followed.

Court of Protection

The Court of Protection is a court that if applied to, can make decisions about an individual’s health, welfare, finances and property under the Mental Capacity Act 2005.

The types of decisions the court can rule on include:
Whether an individual has capacity to make a decision, whether a decision is in an individual’s best interests, removing an attorney under a lasting power of attorney.

The Court of Protection always makes decisions in an individual’s best interests.

Question 31

What is a DNAR?

Answer 31

DNAR does not exclude other treatment
• DNAR=AND(Allow Natural Death)
• Plans need to be made before the event
• But majority of decisions only made within the last 48 hours

Question 32

When is CRP given and why is DNACPR put in place?

Answer 32

CPR can be successful in selected situations
– (44% success at 20 min; 13-15% survive to
(44%
• CPR generally has low chance of success in
frail and with chronic pain illness and malignancy
• Burdens and risks include:
– Probably transfer to ITU, undignified death, rib
fractures,hypoxic brain

A Do Not Attempt CPR (DNACPR) decision can also be known as Do Not Attempt Resuscitation (DNAR)

A DNACPR decision provides information to healthcare professionals present on the best action to take if an individual suffers a cardiac arrest. A DNACPR is recorded, normally on a CPR Decision form, but is not in itself legally binding. This means that a doctor can overrule an existing DNACPR if they believe the circumstances do mean CPR would be in the patient’s best interests.

A DNACPR can be made if cardiac or respiratory arrest is an expected part of the dying process, and either CPR will not be successful, or if CPR may be successful but the clinical outcomes (e.g. trauma and prognosis) mean it is not clinically appropriate. A patient with capacity may also refuse CPR.

Best Interests

Doctors can ultimately make the decision to put a DNACPR in place if it is in the patient’s best interests, even if the patient themselves or their family disagrees. However, following a legal case in 2014, doctors must engage the patient and those close to them on the decision to make a DNACPR, and inform them if the decision to make a DNACPR order has occurred.

R (Tracey) v Cambridge University Hospitals NHS Foundation Trust, 2014

Janet Tracey died in Addenbrooke’s Hospital in March 2011. She had been diagnosed with terminal lung cancer and had subsequently been involved in a car crash, in which she sustained a spinal injury. She required ventilation in the Intensive Care Unit (ICU), and after attempts to remove her from the ventilator were unsuccessful, a DNACPR notice was placed in her medical notes. Neither Janet Tracey nor her family were consulted about or informed of this decision.

The legal case concluded in favour of Tracey, finding that her Human Rights had been breached. The case acknowledged that the decision to put a DNACPR in place is ultimately a medical decision, and patients cannot demand treatment. But, the case did result in changes to DNACPR guidance:

Firstly, the decision to not tell a patient about a DNACPR notice can no longer be based on the fact that telling them would cause “distress”. Only if discussing a DNACPR order would cause the patient “physical or psychological harm”, can doctors justify not discussing it. In other circumstances, doctors are legally obliged to discuss a DNACPR order that has been made.

Secondly, it used to be the case that doctors were not obliged to discuss a DNACPR decision if the clinical decision has been made that CPR would be futile. This case amended this, making it a legal obligation for doctors to inform the patient that a DNACPR decision has been made, regardless of whether or not CPR could ever be successful (i.e. futility of CPR is justification for doctors making a best interests decision to make a DNACPR order - even if the patient wants CPR, but doctors are still legally obliged to inform the patient that a DNACPR order has been made).

A DNACPR decision relates only to CPR, and is not a refusal of any other treatment.

Question 33

What are anticipatory medication and when is it given?

Answer 33

End of life care

Medications used in end of life care aim to relieve troublesome symptoms. They are commonly prescribed as ‘anticipatory’ or ‘just in case’ medications for a patient known to be nearing the end of life.

They can be administered:

Oral: if the patient is safely able to swallow
Subcutaneous
Intramuscular
Intravenous
Via continuous subcutaneous syringe pump
Medications for pain

Conversion of patient’s usual daily dose of opiate analgesia to a 24 hour dose for use via a syringe pump, with 1/6-1/10 of the daily dose prescribed as ‘breakthrough’ analgesia. Should be reviewed every 24 hours.

Morphine
First line for pain management
Good for all types of pain
Monitor for constipation
Monitor for unwanted sedation
Diamorphine
Oxycodone
Alfentanyl
Useful for patients with renal failure who cannot take morphine
 Medications for breathlessness

May be a result of disease process (e.g. lung cancer, anaemia)
Therapeutic oxygen
Morphine
Midazolam
Medications for nausea and vomiting

Levomepromazine
Cyclizine
Haloperidol
Metoclopramide
Medications for restlessness and confusion

Haloperidol
Levomepromazine
Midazolam
Medications for respiratory tract secretions

Hyoscine hydrobromide
Hyoscine butylbromide
Glycopyrronium

Question 34

When is it justified to withdraw or withhold treatment?

Answer 34

GMC Guidance

The General Medical Council (GMC) provides guidance to doctors on withdrawing and withholding treatments. It describes three situations in which this is justified.

Patient with Capacity Refuses

Firstly, if a patient with capacity refuses. In this scenario, the patient’s autonomy must be respected. This is the case even if medically-speaking it is a “bad” decision to refuse treatment, or not what the doctor would have done themselves.

Patient Lacks Capacity

Secondly, if a patient lacks capacity but has made an Advanced Statement or Advanced Decision to Refuse Treatment detailing their wish not to have a specific treatment, then withholding or withdrawing treatment is justified.

Best Interests

And finally, if a treatment is not in the best interests of a patient, then the doctor is justified in withholding or withdrawing it. For example, if a patient with a viral infection demands antibiotics, the doctor is justified in withholding that treatment as giving it would not be in their best interests.

Question 35

What drugs are considered safe and unsafe in kidney failure?

Answer 35

Prescribing in patients with renal failure

Questions regarding which drugs to avoid in renal failure are common

Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin

Drugs likely to accumulate in chronic kidney disease - need dose adjustment
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin
digoxin, atenolol
methotrexate
sulphonylureas
furosemide
opioids

Drugs relatively safe - can sometimes use normal dose depending on the degree of chronic kidney disease
antibiotics: erythromycin, rifampicin
diazepam
warfarin

Question 36

How to differentiate between acute and chronic renal failure?

Answer 36

Best way to differentiate is renal ultrasound - most patients with CRF have bilateral small kidneys

Exceptions
autosomal dominant polycystic kidney disease
diabetic nephropathy
amyloidosis
HIV-associated nephropathy

Other features suggesting CRF rather than ARF
hypocalcaemia (due to lack of vitamin D)

Question 37

How can Aki be classified?

Answer 37

Acute kidney injury (AKI) is defined as a rapid (within 7 days) and sustained (lasting >24 hours) reduction in renal failure resulting in oliguria and a rise in serum urea and creatinine.

Unlike chronic kidney disease, AKI is usually reversible.

Classification

The KDIGO is a common classification system used to risk stratify AKI:

Stage 1: creatinine rise of 1.5x compared to baseline or urine output <0.5 ml/kg/hour for 6 hours.
Stage 2: creatinine rise of 2x compared to baseline or urine output <0.5 ml/kg/hour for 12 hours.
Stage 3: creatinine rise of 3x compared to baseline or urine output <0.3 ml/kg/hour for 24 hours (or anuria for 12 hours) or serum creatinine >354umol/dl

Question 38

What are the causes for AKI?

Answer 38

Pre-renal Causes

Shock (hypovolaemic, cardiogenic, or distributive)
Renovascular disease (such as renal artery stenosis).
Pre-renal causes account for approximately 55% of cases.

Renal Causes

Dysfunction in the glomeruli (as in acute glomerulonephritis)
Tubules (as in acute tubular necrosis)
Interstitial (as in acute interstitial nephritis)
Renal vessels (as in haemolytic uraemia syndrome or vasculitides).
Renal causes account for approximately 35% of cases of AKI.

Post-Renal Causes

Caused by obstruction to urinary outflow
Luminal (e.g. a kidney stone)
Mural (e.g. a tumour of the urinary tract)
Due to external compression (e.g. being prostatic hypertrophy).
Post-renal causes account for approximately 20% of cases of AKI.

Question 39

what are the risk factors for AKI?

Answer 39

An increased risk of AKI is associated with:

Chronic kidney disease
Diabetes with chronic kidney disease
Heart failure
Renal transplant
Age 75 or over
Hypovolaemia
Contrast administration
Source: NICE clinical guideline CG169 (August 2013).

Question 40

How can Aki be investigated?

Answer 40

Investigations

Bloods: FBC, U&E, LFT, glucose, clotting, calcium, ESR
ABG: hypoxia (oedema), acidosis, potassium
Urine: dip, MCS, chemistry (U&E, CRP, osmolality, BJP)
ECG: hyperkalaemia
CXR: pulmonary oedema
Renal US: Renal size, hydronephrosis
Glomerulonephritis screen may be required if the cause is unclear

Question 41

How can AKI be managed?

Answer 41

Management

As with all acute presentations, the general approach to acute kidney injury should initially follow the DR ABCDE algorithm.

A: is the airway compromised?
B: Acute kidney injury can be associated with critical illness. It may also result in pulmonary oedema. This should be managed in section ‘B’ by sitting the patient up, giving high flow oxygen, and IV furosemide with diamorphine.
C: it is helpful to assess the fluid status in (C). If the patient is hypovolaemic they will require intravenous fluid resuscitation.
Any life-threatening complications should then be identified and treated e.g. hyperkalaemia, sepsis, pulmonary oedema.

The cause should then be identified and treated appropriately:

Pre-renal AKI: give fluids if the patient is hypovolaemic, give intravenous antibiotics if the patient is septic. Stop nephrotoxic drugs.
Renal AKI: A nephrology review is often required to identify less common causes of Acute Kidney Injury
Post-renal AKI: catheterisation and urology review.
The patient should be also monitored carefully with regular observations, fluid status, and measurement of urine output (usually with a catheter) and U&Es.

Medication Review

In a patient with an acute kidney injury remember to review the drug chart.

Suspend nephrotoxic drugs: NSAIDs, aminoglycosides e.g. gentamicin, ACE inhibitors/ARBs, and diuretics.
Suspend renally excreted drugs: metformin, lithium, digoxin.
Adjust renally excreted drugs e.g. opioids.
Indications for Dialysis

Question 42

What are the indications for dialysis in AKI?

Answer 42

Indications for acute dialysis can be remembered by the mnemonic AEIOU:

Acidosis (severe metabolic acidosis with pH of less than 7.20)
Electrolyte imbalance (persistent hyperkalaemia of more than 7 mM
Intoxication (poisoning)
Oedema (refractory pulmonary oedema)
Uraemia (encephalopathy or pericarditis).

Question 43

How can chronic kidney disease be classified?

Answer 43

Definition

Chronic Kidney Disease (CKD) is defined as a gradual, irreversible decline in kidney function. The KDIGO 2012 guidelines outline the criteria for the presence of CKD.

This requires either a decreased GFR (below 60 ml/min/1.73m,2) or markers of kidney damage (albuminuria, electrolyte abnormalities, structural or histological renal abnormalities) present for >3 months.

Epidemiology

CKD has an estimated prevalence in England of 15% in people >35 years.

Staging

Stage 1 CKD if eGFR is >90 ml/min/1.73m2 with demonstrable kidney damage (e.g. haematuria or proteinuria).
Stage 2 CKD if eGFR is 60-89 ml/min/1.73m2 with demonstrable kidney damage (e.g. haematuria, proteinuria, or raised urine albumin/creatinine ratio).
Stage 3 CKD if eGFR is 30-59 ml/min/1.73m2.
Stage 4 CKD if eGFR is 15-30 ml/min/1.73m2.
Stage 5 CKD if eGFR is <15 ml/min/1.73m2.
NB: The patient is typically asymptomatic until stage 4 or stage 5 CKD.

Question 44

What are the causes of CKD?

Answer 44

Causes

Causes of chronic kidney disease can be classified as follows:

Glomerular causes can be primary (such as IgA nephropathy) or secondary (such as SLE).
Vascular causes include vasculitis and renal artery stenosis.
Tubulointerstitial causes include amyloidosis and myeloma.
Congenital causes include polycystic kidney disease and Alport syndrome
Systemic causes such as diabetes and hypertension.
Developmental causes such as vesico-urteric reflux causing chronic pyelonephritis.
The most common causes of chronic kidney disease include:

Diabetes
Hypertension
Chronic glomerulonephritis
Polycystic kidney disease

Question 45

what are the complications of CKD?

Answer 45

Complications

The complications of chronic kidney disease (CKD) can be understood by considering the key functions of the kidney.

Waste excretion - Uraemia and hyperphosphataemia
Regulation of fluid balance - Hypertension and peripheral/pulmonary oedema.
Acid-base balance - Metabolic acidosis.
Erythropoietin production - Anaemia.
Activation of vitamin D - Hypocalcaemia.
CRF HEALS is a useful mnemonic to remember the complications of CKD:

CRF HEALS

Cardiovascular disease
Renal osteodystrophy
Fluid (oedema)
Hypertension
Electrolyte disturbance (hyperkalaemia, acidosis)
Anaemia
Leg restlessness
Sensory neuropathy
NB: Cardiovascular disease is the most common cause of death in chronic kidney disease.

Renal Osteodystrophy

Features:

Reduced bone density (Osteoporosis)
Reduced bone mineralisation (Osteomalcia)
Secondary/Tertiary Hyperparathyroidism
May get spinal osteosclerosis: 􏰃Rugger Jersey spine
Microalbuminuria in CKD

Microalbuminuria can be caused by diabetic nephropathy.

Progression can lead to overt nephropathy and chronic kidney disease.

All patients with diabetes over the age of 12 should undergo regular urinary albumin:creatinine ratio to screen for microalbuminuria. If microalbuminuria is detected (>2.5 mg/mmol in men, >3.5 mg/mmol in women), patients should be started on an ACE inhibitor.

Question 46

How can CKD be managed?

Answer 46

For the management of oedema conservative measures include fluid and salt restriction. Medical management includes the use of diuretics e.g. furosemide.

For the management of anaemia patients should be administered monthly subcutaneous erythropoietin (with target haemoglobin of 10-12 g/dL).

For the management of hypocalcaemia and hyperphosphataemia patients should be advised to restrict dietary potassium (found in dairy products and eggs) and can be prescribed sevelamer (a phosphate binder) and alfacalcidol (a 1-hydroxylated vitamin D analogue. Parathyroidectomy is an option in patients with tertiary hyperparathyroidism (PTH >28 mmol/L).

Question 47

How does polycystic kidney disease present?how is it inherited?

Answer 47

Polycystic kidney disease (PKD) is an inherited disorder in which clusters of cysts develop primarily within the kidneys, causing them to enlarge and lose function over time.

2 genetic loci have been identified: polycystic kidney disease 1 (85%) and polycystic kidney disease 2.

Autosomal dominant PKD typically presents during adolescence and 50% of patients will require dialysis by the age of 50.

Autosomal recessive inherited polycystic kidney disease often results in a non-viable pregnancy or death in early infancy.

Children born with ARPKD often, but not always, develop kidney failure before reaching adulthood; babies with the worst cases die hours or days after birth due to respiratory difficulties or respiratory failure. Liver scarring occurs in all patients.

Presentation

Renal cysts
Extrarenal cysts
Intracranial aneurysm (Berry aneurysms)
Hypertension
Chronic kidney disease
Abdominal wall hernias
Abdominal mass and associated pain
Haematuria
Headaches

Question 48

How is PCKD managed?

Answer 48

Treatment

Aggressive blood pressure control using an ACE inhibitor and/or angiotensin-II receptor blocker
Prompt treatment for urinary tract infections with antibiotics
Quinolones treatment for infected renal cysts
Pain relief
Neurosurgical intervention for intracranial aneurysm
Dialysis and transplant in end stage renal disease

Question 49

What are the complications of PCKD?

Answer 49

Complications

Left ventricular hypertrophy
Mitral valve prolapse
Aortic root dilation
Gastro-oesophageal reflux disease
Ruptured intracranial aneurysm
Sepsis
Higher risk of gestational hypertension and pre-eclampsia during pregnancy

Question 50

What are the different options and mechanism for dialysis?

Answer 50

Chronic kidney disease (CKD) is a relatively common condition, affecting 1 in 8 people in the UK. Around 10% of those with CKD will go on to develop renal failure, which is defined as a glomerular filtration rate of less than 15ml/min. For patients with renal failure, the management options are renal replacement therapy (RRT), to take over the physiology of the kidneys, or conservative management, which will be palliative.

There are several types of renal replacement therapy available to patients:
haemodialysis
peritoneal dialysis
renal transplant

The decision about which RRT option to pick should be made jointly by the patient and their healthcare team, taking into account the following:
predicted quality of life
predicted life expectancy
patient preference
co-existing medical conditions

Haemodialysis is the most common form of renal replacement therapy. This involves regular filtration of the blood through a dialysis machine in hospital. Most patients need dialysis 3 times per week, with each session lasting 3-5 hours. At least 8 weeks before the commencement of treatment, the patient must undergo surgery to create an arteriovenous fistula, which provides the site for haemodialysis. Most commonly this is created in the lower arm. Some patients may be trained to perform home haemodialysis so that they do not have to regularly attend hospital.

Peritoneal dialysis is another form of renal replacement therapy where the filtration occurs within the patient’s abdomen. Dialysis solution is injected into the abdominal cavity through a permanent catheter. The high dextrose concentration of the solution draws waste products from the blood into the abdominal cavity across the peritoneum. After several hours of dwell time, the dialysis solution is then drained, removing the waste products from the body, and exchanged for new dialysis solution. There are two types of peritoneal dialysis:
Continuous ambulatory peritoneal dialysis (CAPD) - as described above, with each exchange lasting 30-40 minutes and each dwell time lasting 4-8 hours. The patient may go about their normal activities with the dialysis solution inside their abdomen
Automated peritoneal dialysis (APD) - a dialysis machine fills and drains the abdomen while the patient is sleeping, performing 3-5 exchanges over 8-10 hours each night
Mechanism of Haemodialysis and Haemofiltration

Haemodialysis works by creating a counter-current flow.

Blood and dialysate flow on opposite sides of the semi-permeable membrane, and solute transfer occurs by diffusion.

Haemofiltration enables fluid removal by decreasing hydrostatic pressure of the dialysate. Solute movement occurs via convection rather than diffusion. Haemofiltration is typically used in patients who cannot tolerate rapid changes in haemodynamic parameters, and is often given in the ITU setting.

Peritoneal dialysis works by administering the dialyse into the peritoneal cavity. Waste solutes diffuse into the dialysate across the peritoneum (which acts as a semi-permeable membrane). Ultrafiltration (to draw water from the peritoneal cavity) occurs by the addition of osmotic agents to the dialysate (typically 1.5% glucose solution).

Question 51

What are the complications of hemodialysis?

Answer 51

Complications of Haemodialysis

Cardiovascular disease
Fistula complications: stenosis, aneurysm, infection, steal syndrome, heart failure
Hypotension
Amyloidosis (secondary to build up of B2 microglobulin)
Dialysis disequilibrium syndrome (acute cerebral oedema due to rapid extraction of osmotically active substances)

Question 52

What are complications for peritoneal dialysis?

Answer 52

Complications of peritoneal dialysis

Complications of peritoneal dialysis include peritoneal dialysis peritonitis.
This is typically caused by Staphylococcus epidermidis.
The patient presents with abdominal pain, fever, and a cloudy dialysis bag.
The peritoneal dialysis fluid should be sent for culture.
Management is with intraperitoneal and systemic antibiotics.
Other complications of peritoneal dialysis include catheter malfunction, obesity (due to absorption of glucose from the dialysate fluid),
and hernias.

Question 53

When is renal transplantation done?

Answer 53

Renal transplantation involves the receipt of a kidney from either a live or deceased donor. The average wait for a kidney in the UK is 3 years, though patients may also receive kidneys donated by cross-matched friends or family. The donor kidney is transplanted into the groin, with the renal vessels connected to the external iliac vessels. The failing kidneys are not removed. Following transplantation, the patient must take life-long immunosuppressants to prevent rejection of the new kidney. The average lifespan of a donor kidney is 10-12 years from deceased donors and 12-15 years from living donors.

Question 54

What are the complications of renal replacement therapy?

Answer 54

omplications of renal replacement therapy

Haemodialysis Peritoneal dialysis Renal transplantation
Site infection Peritonitis DVT / PE
Endocarditis Sclerosing peritonitis Opportunistic infection
Stenosis at site Catheter infection Malignancies (particularly lymphoma and skin cancer)
Hypotension Catheter blockage Bone marrow suppression
Cardiac arrhythmia Constipation Recurrence of original disease
Air embolus Fluid retention Urinary tract obstruction
Anaphylactic reaction to sterilising agents Hyperglycaemia Cardiovascular disease
Disequilibration syndrome Hernias Graft rejection
Back pain
Malnutrition

Question 55

What symptoms develop without RRT?

Answer 55

The average life expectancy of a patient with renal failure that does not receive renal replacement therapy is 6 months. The symptoms of renal failure that is not being adequately managed with RRT are:
breathlessness
fatigue
insomnia
pruritus
poor appetite
swelling
weakness
weight gain/loss
abdominal cramps
nausea
muscle cramps
headaches
cognitive impairment
anxiety
depression
sexual dysfunction

Question 56

Read

Answer 56

https: //www.nice.org.uk/guidance/ng31/chapter/Recommendations#recognising-when-a-person-may-be-in-the-last-days-of-life
https: //www.nice.org.uk/cks-uk-only

Dr ong lecture