Treatment escalation and withdrawal Flashcards
What is frailty?
An age related, multi dimensional state of decreased physiological reserves
Why do the elderly get more frail?
Physiological changes:
- Changes in body composition with loss of lean body mass.
- Loss of muscle strength and poor balance
- Decline in renal function
- Changes in metabolism of drugs cleared by the liver.
- Changes in CNS = means sedative drugs have very big effect in elderly.
How to assess for frailty?
GP records
- use traffic light prognosis
- GSF (gold standard framework)- A way of reflecting on services &how to care for people who are dying
- Agreed targets on how to care for someone who is dying
PRISMA 7
- patient asked 7 questions e.g. Are you older than 85? Are you male?
- A score of 3 or more suggests frailty
gait speed test
- An average gait of longer than 5 seconds to walk 4m indicates frailty
- Usually repeated 3 times with adequate rest time in between tests
- If frail may refer the patient to a PT/OT for an in house assessment
What to do once frailty has been recognised?
DEPRESCRIBE:
- Each drug left on the medication list should be justified
- Each drug should not be causing side effects
- Each drug should be easy for the patient to manage
Use STOPP START tool
Why do we deprescribe?
- Co-morbidities are common - older people on multiple meds.
- Trend for prescribing for prevention = patients accumulate drugs
Therefore, reducing treatment burden may optimise & improve quality of care
What should be discussed with the patient whilst deprescribing?
- Ways of maximising benefit from existing treatment
- Treatments that could be stopped because of limited benefit
- Treatments & follow up arrangements w/ high burden that are no longer required
- Medicines w/ higher risk of adverse events (falls, GI bleeding, acute kidney injury)
- Non pharmacological treatments as possible alternatives
- the purpose of the approach to care =to improve quality of remaining life
What is the STOPP START tool?
Screening tool of older people’s potentially inappropriate prescriptions
Done by GP, specialist nurse, pharmacist
How to decide to withdraw care?
- When futility is established - the point at which recovery to a quality of life that the patient would find acceptable has passed
- When patient becomes bed bound, semi-comatose, unable to take tablets, only able to take sips of water, no reversible cause
How may the withdrawal of treatments and care improve quality of life?
- Treatments & follow arrangements are high burden for the patient & carers
- Medications may have adverse effects e.g. dizziness leading to falls, GI bleeding, kidney damage
- Non-pharmacological treatments may be a better alternative
- Alternative arrangement for follow ups may improve coordination & optimise appointment numbers
What to do when the fact that the patient is going die has been established? I.e how to improve their QOL
- Discuss w/ patient or family Before changing any medication
- Only interventions that improve QOL of patients remaining life should be offered
- Stop non essential medications that do not contribute to symptom control & inappropriate investigations e.g. obs
- Often acceptable to continue sedatives & analgesics, as reducing or stoping them can cause unnecessary pain & agitation
- Any measures for prolonging life should be withdrawn
- Complete DNACPR form
- Symptom control, relief of distress & care for family become most important elements
- If patient is going to go home ensure availibility of parenteral medication for symptom relief
- Make sure family know what they have to do while caring for the patient back home before they die
What happens after death?
- Once brain death or cardiac death has been confirmed, organ donation should be considered
- Many patients will have expressed their wishes through organ donor registration scheme, or agreement of family/next of kin is sometimes legal
- A post mortem examination may be agreed, either by the coroner (if there was an unexpected/violent/suspicious death) or by physicians in aim to enhance medical knowledge/understanding of family
Discuss the ethical considerations when communicating with a patient about their death.
Most important thing when managing death is to listen to patient & family & take their wishes on board.
Patients want their doctors to recieve & understand the information that the patient is giving to them in the context of the patient, their illness & needs, their carers & socioeconomic context.
- I.E holistic care
Effective interdisciplinary teamwork very important
Discuss the ethical considerations for when a family member/s has to care for a dying patient at home
Families can be unprepared for challenges of caring for a dying person.
- exhausting emotional & physical experience
- fatigue can build up
Good anticipatory care means not just providing for new physical symptoms, but also planning for any time when care at home becomes no longer possible
