Station renal, palliative Flashcards
What medication would you be most appropriate for confusion at end of life?
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
Why would it not be appropriate for patient to die at home
Patient preference to stay in hospital or carere distress
Not having a good support system
Distressing symptoms needing hospital support
What are the causes confusion at end of life?
frality,polypharmcy,infections,brain metastasis,delirum
What to expect once dialysis has stopped?
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.
Who are the palliative healthcare providers?
Interrelated professionals from various disciplines such as :
Doctors Nurses Social workers Pharmacist Dietitian Massage therapist Others
What are the services provided under palliative care?
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
What are the different categories of support in palliative care?
- Pain management
- Symptom management : gastrointestinal , weakness,fatigue, urogenital issues, delirium , shortness of breath etc
- Spiritual and emotional support
How can pain be managed?
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
What adjuvant drugs can be used for pain?
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
What to if the pain is uncontrolled?
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
What needs to be considered when giving analgesia?
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
How can gastro intestinal symptoms be managed?
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
How can nausea and vomiting be managed?
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
How can respiratory symptoms be managed?
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
How can other physical symptoms be managed?
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
How can non-physical symptoms be managed?
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
What non drug treatment can offered at end of life?
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
What is hospice care?
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.
What prognostic tools can be used?
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
What are the trajectories of decline?
Sudden death: 14%
• Organ failure: 19%
• Malignant disease: 21%
• Frailty/dementia: 42%
What are the 4 dimensions of dying?
Physical
psychological
social
spiritual
What are the stages of bereavement?
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
What is discussed in advanced care planning?
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
What are some general indicators of decline?
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
What are some supportive and palliative care indicators tool?
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
What are the signs of diagnosis?
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
What should the patient care plan include?
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
What are the ethical principles?
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
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How can capacity be assessed?
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.
What other documents can be used for advanced care planning
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.
What is a DNAR?
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
When is CRP given and why is DNACPR put in place?
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.
What are anticipatory medication and when is it given?
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
When is it justified to withdraw or withhold treatment?
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.
What drugs are considered safe and unsafe in kidney failure?
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
How to differentiate between acute and chronic renal failure?
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)
How can Aki be classified?
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
What are the causes for AKI?
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.
what are the risk factors for AKI?
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).
How can Aki be investigated?
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
How can AKI be managed?
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
What are the indications for dialysis in AKI?
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).
How can chronic kidney disease be classified?
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.
What are the causes of CKD?
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
what are the complications of CKD?
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.
How can CKD be managed?
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).
How does polycystic kidney disease present?how is it inherited?
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
How is PCKD managed?
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
What are the complications of PCKD?
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
What are the different options and mechanism for dialysis?
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).
What are the complications of hemodialysis?
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)
What are complications for peritoneal dialysis?
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.
When is renal transplantation done?
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.
What are the complications of renal replacement therapy?
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
What symptoms develop without RRT?
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
Read
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
