Terminal Care Flashcards
What are the prinicples of palliative & end of life care?
- Involving patient and those close to them
- giving access and early referral to specialist palliative care services for patient and family support if needed
- HCP collaboration
- appropriate, regular & tailored medications for individual patients for symptom relief and prevention
- regular assessment and support
- emergency back-up available 24 hours a day
What is the definition of end of life care?
- –> the care experienced by people who have an incurable illness and are approaching death
- covers the care received by people who are likely to die:
- in the next 12 months,
- as well as care in the last days and hours of life,
- and care after death, including
- bereavement support for families and loved ones.
What kind of conditons are included in end of life care?
- advanced, progressive, incurable conditions
- general frailty and coexisting conditions that mean they are expected to die within 12 months
- existing conditions if they are at risk of dying from a sudden acute crisis in their condition
- life-threatening acute conditions caused by sudden catastrophic events.
What does end of life care aim to achieve?
- Aims to help people live as well as possible and to die with dignity
- Earlier identification of people leads to earlier planning and better co-ordinated care
There are challenges to prognostication in end of life care - there are 3x ways of dying:
- Rapid
- Erratic
- Slow
Give examples of conditions for each.
- Rapid –> Cancer - fine until you can no longer cope/compensate then rapid drop
- Erratic –> Organ failure, (graph dips) - progressive decline with intermittent exacerbations
- Slow e.g. dementia & frailty
Below are v. importnant points, what do they represent?
- Maintaining dignity and privacy
- To retain a degree of choice and control
- To have an understanding of what to expect
- Adequate relief from pain and other symptoms
- The opportunity to ensure wishes are respected
- Advance care planning
- In some cases an Advanced decision to refuse treatment (ADRT)
- To die naturally and not have life prolonged pointlessly
the concept of a “good” death
What isssues are important when someone is dying?
- Treatment decisions
- Concerns
- Who to involve
- Where to be
What things does a palliative care clinician need to consider for a “good” death?
- Likely disease path and symptoms
- Patient’s priorities
- Information needs
- Realistic options
- Timing of decision making and planning
What tools are available to use for palliative care indicators?
- GSF prognostic indicator guidance
- SPICT - supportive and palliative care indicators tool
One prognostic indicator tool involves:
- looking for 2+ general indicators of deteriorating health
another prognostic indicator involves:
- asking the surprise question,
- general indicators of decline
- and specific clinical indicators related to certain condtions.
Which tool is which?
- asking the surprise question, general indicators of decline and specific clinical indicators related to certain condtions. = GSF prognostic indicator guidance
- looking for 2+ general indicators of deteriorating health = SPICT (supportive and palliative care indicators tool)
What is the surpise question in palliative care (GSF prognostic indicator guidance)?
Would you be surprised if this patient were to die in the next few months? weeks? days?
What are the general indicators of decline (GSF prognostic indicator guidance)?
Which one is biggest predictor?
- Decreasing activity
- co-morbidity! <- regarded as the biggest predictive indicator of M&M
- general physical decline & inc need for support
- Advanced disease (unstable and deteriorating syx)
- decreasing response to Rx, dc reversability
- choice of no further active treatments
- >10% weight loss in past 6 months
- repeated unplanned admissions
- sentinel event e.g. serious fall, berevement, transfer to nursing home
- <2.5g/l serum albumin
How can you tell someone is “decreasing their acitvity” in general incdicators of decline (GSF prognostic indicator, palliative care)
Barthel score (is of ADLs basically, 100/100 is independence - like a percent of what acitivities they can do)
&
increased dependence in most ADLs
Dementia and frailty both have specific clinical indicators of decline.
What are these for dementia?
- unable to walk without assistance,
- incontinence,
- no consistently meaningful conversation,
- unable to do ADLs - Barthel score <3, UTIs,
- stage 3-4 pressure sores,
- recurrent fever,
- reduced oral intake,
- aspiration pneumonia
Dementia and frailty both have specific clinical indicators of decline.
What are these for frailty?
- multople co-morbidities with significant impairment in day to day living
What do these criteria represent?
- Performance status is poor or deteriorating
- (the person is in bed or a chair for 50% or more of the day);
- reversibility is limited.
- Dependent on others for most care needs due to physical and/or mental health problems.
- 2+ unplanned hospital admissions in the past 6 months.
- Significant weight loss (5-10%) over the past 3-6 months, and/ or a low body mass index.
- Persistent, troublesome symptoms despite optimal treatment of underlying condition(s).
- Patient asks for supportive and palliative care, or treatment withdrawal.
SPICT or supportive and palliative care indicators tool
- where you look for 2+ or more general indicators of deteriorating health
What clinical indicators of one or more advanced conditions maybe seen with neurological disease?
- Progressive deterioration in physical and/or cognitive function despite optimal therapy.
- Speech problems with increasing difficulty communicating and/or progressive swallowing difficulties.
- Recurrent aspiration pneumonia; breathless or respiratory failure.
How is advanced care planning undertaken?
(see picture attached for Gold standards framework - advance care planning summary)
This is a PROCESS, not a one-off conversation, and it may include the following:
- Values, beliefs and wishes
- Preferences about care, treatment and information
- Anything the patient would wish to avoid happening to them
- Communication and consultation with others
- Organising affairs (e.g. a Will, Lasting Power of Attorney)
- CPR decision making
See the attached image.
This is a care in the last few days of life pathway. What one is this?
this is from the:
- Leadership Alliance for the Care of Dying People: ‘one chance to get it right’ 2014
- (is the new/amendement to the Liverpool Care Pathway)
focuses on individualised care planning by guiding prinicples for HCP to identify the 5 key priorities for care:
- Recognise that the patient may die within the next few days or hours
- Communicate this clearly and sensitively
- Make decisions in accordance with the person’s needs and wishes, involving the patient and those close to them
- Regularly review interventions and revise decisions as needed
- Ensure that the needs of those close to the patient are explored, respected and met as far as possible (support)
- An individual plan of care including food and drink, symptom control psychological, social and spiritual support, is agreed, coordinated and delivered with compassion
