Week 1: Older people (1) (Capacity, CGA, discharge, DNAR, prescribing) Flashcards
1
Q
what is capacity and when should it be assessed
A
Ability to make a decision or take action that affects ones life.
- Capacity is doubted
- Significant decision is to be made
2
Q
principles of having capacity to make a decision
A
Mental Capacity Act 2007
To have capacity a person must be able to :
- Understand the information relevant to the decision
- To retain that information
- To weigh that information as part of the process of making a decision
- To communicate his/her decision
3
Q
best interest decision
A
- Made on behalf of person lacking capacity AND lack of LPA health/valid Advanced Statement
4
Q
best interest decision
A
- Made on behalf of person lacking capacity AND lack of lasting power of attorney (LPA) health/valid Advanced Statement
5
Q
considerations made for best interest decisions
A
- Is lack of capacity temporary or permanent?
- Which options would provide overall benefit?
- Which option is least restrictive of patient’s future choices?
- Has patient any previously expressed preferences (advanced decision/statement)?
- Have you considered the view of those close to the patient and whether they believe this is in the patient’s best interests?
- Any decision made must be in the best interests of the person
6
Q
who to consult for best interest decisions
A
- Next of kin (NoK)
- Family/friends
- Persons involved in care
- IMCA (independent mental capacity advocate)
- If no representatives exist and decision can wait
- Decision long term placement
- Only advises, final decision with healthcare team
7
Q
ReSPECT form
A
8
Q
what is a comprehensive geriatric assessment
A
a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up
- quality of life
- functional status
- prognosis
- outcome
9
Q
A typical CGA team comprises
A
geriatrician, nurse specialist, occupational therapist, physiotherapist, pharmacist and others as needed (speech and language therapist, dietician)
10
Q
domains of CGA
A
- Problem list – current and past
- Medication review
- Nutritional status
- Mental health – cognition, mood and anxiety, fears
- Functional capacity - basic activities of daily living , gait and balance, activity/exercise status, instrumental activities of daily living
- Social circumstances - informal support available from family or friends, social network such a visitors or daytime activities, eligibility for being offered care resources
- Environment - home environment, facilities and safety within the home environment, transport facilities ,accessibility to local resources
11
Q
main aim of discharge planning
A
- Reduce length of stay in hospital
- Prevent unplanned re-admission
- Improve manner in which community services co-ordinate following discharge
12
Q
normal discharge
A
- Referral made to SS to access funding e.g. for care home or package of care (this is a section 2)
- Social worker then allocated to the patient and is responsible for putting together package of care
- Section 5 then sent by nursing staff to social services, alerting them to the fact that the patient is ‘medically stable for discharge’
- Social services incur a financial penalty if they are responsible for a delayed discharge
13
Q
discharge involves
A
- Medication to take home (TTO’s).
- Transport.
- Therapy assessment – ongoing referral to community Occupational Therapy or Physiotherapy if required. Equipment delivery or adaptations to home if required
- Restarting package of care. – If more complex or not in place a section 2 may be involved to arrange
- Outpatient/user’s appointment.
- District nurse referral if required or palliative care or community lead referral if warranted
- Transfer back letter for residential/nursing home
14
Q
why do discharge’s fail
A
- Unsuitable package of care
- Patient/user health complications.
- Communication breakdown between health care professionals and Social Services.
- Family decisions.
- Decisions around funding.
15
Q
end of life decision making principles
A
- advanced decision making by patients
- palliation
- individualised care
- maximising quality of life e.g. letting patients eat and drink
- comfort and dignity
- following advanced directives
16
Q
advanced directives
A
Some patients may have advanced directives stating how they would wish to be managed during this phase of their life if they are unable to communicate for themselves.
These must be seen and reviewed. Patients are able to refuse treatment but not request treatment
17
Q
when a patient lacks capacity
A
- Make care of patient first concern
- Treat patients as individuals and respect their dignity
- Support patients to be involved
- Treat patients with respect and do not discriminate against them
- Use any advocates the person may have previously identified
- Decisions must take into consideration what the person would have wanted should they have had the capacity to make a decision
18
Q
important things to consider in regards to capacity
A
19
Q
breaking bad news consider..
A
- preparation and setting
- specialist nurse, translator, friend/relative
- expectations
- establish what is currently known
- delivery
- warning
- direct
- pauses
- jargon
- responses
- allow time
- repetition
- establish a plan
- am i okay?
20
Q
End of life or the dying phases
A
- Bed bound.
- Semi comatose.
- Only able to take sips of fluid.
- Unable to take medicine orally
21
Q
Symptoms facing people at the end of their life include o Pain
A
- Nausea and Vomiting
- Dyspnoea
- Agitation
- Confusion
- Constipation
- Anorexia
- Terminal Secretions
22
Q
Palliative care
A
Caring for people with life limiting illness → optimise quality of life
-
Holistic approach
- Biological=medical
- Psychol
- Social
- spiritual
23
Q
anticipatory medicine for palliative care
A
24
Q
‘Ps of palliative care’
A
25
**Preferred place of death**
* A preferred place of death is the place the person wishes to end their life
* This may not always be possible
* Options include:
* Home **(majority of patients)**
* Care Home
* Or if imminent – community hospital, hospital, hospice
26
death confirmation
* **Know background**
* Read notes
* Confirm DNACPR
* **If family present**
* Introduce self
* Offer condolences
* Explain what you are doing
* Offer opportunity to wait outside/ be present
* Ask if they have any concerns or questions
* **Death confirmation**
27
how to physically confirm death
* wash hands
* confirm identity
* signs of life (5 mins)
* response
* resp efforts
* breath sounds in 2 diff places 92mins)
* carotid pulse (1 minute)
* heart sounds in 2 different places (2 minutes)
* pupils
* fixed and dilated, unreactive to light)
28
confirming death report
29
a death certificate states the cause of death such as
* 1a – Cause of death
* 1b – Condition leading to cause of death
* 1c – Additional condition leading to 1b
* 2 – Any contributing factors or conditions
For example
1a – Type 2 respiratory failure
1b – Congestive Cardiac Failure
1c – Myocardial Infarction
2 – Ischaemic heart disease, Hypertension, Diabetes Mellitus
30
Cremation paperwork is completed by
by **2 independent doctors**, one of whom has cared for the patient.
→ Part 1 is completed by the doctor who knows the patient and part 2 by an independent doctor, two years post registration, seeking confirmation of the cause of death from a variety of sources. To cremate a body pacemakers and radioactive implants must be removed.
31
**A death should be reported to the coroner when the death…**
* occurred as a result of poisoning, the use of a controlled drug, medicinal product, or toxic chemical;
* occurred as a result of trauma, violence or physical injury, whether inflicted intentionally or otherwise;
* is related to any treatment or procedure of a medical or similar nature; o occurred as a result of self-harm, (including a failure by the deceased person to preserve their own life) whether intentional or otherwise;
* occurred as a result of an injury or disease received during, or attributable to, the course of the person’s work;
* occurred as a result of a notifiable accident, poisoning, or disease; o occurred as a result of neglect or failure of care by another person;
* Was otherwise unnatural.
The coroner should also be informed where:
* The death occurred in custody or otherwise in state detention – of whatever cause. This includes Deprivation of Liberty Safeguarding authorisations (DoLS).
* No attending practitioner attended the deceased at any time in the 14 days prior to death or no attending practitioner is available within a reasonable period to prepare an MCCD;
* The identity of the deceased is unknown.
* The coroners role is determine who died, where they died and how they died. They do not comment on care but do have powers to insisit on further local investigation. Coroners can decide to hold an inquest to ascertain the answers to the questions above.
32
define polypharmacy
\>5 medications
*Polypharmacy is often defined as the routine use of five or more medications. This includes over-the-counter, prescription and/or traditional* and complementary medicines used by a patient.
33
**Who should be targeted for medication review**
* Taking lots of medications!
* Complex medication regimens
* E.g. how to take inhaler
* Recently discharged (or admitted)
* Frequent admissions to hospital
* Comorbidities
* Medications prescribed from multiple sources
* High risk medications – narrow therapeutic window, known and serious side effect profile
34
pharmacokinetics and dynamic changes in older people
* Body composition – increased fat, decreased body water and lean mass
* Renal mass and function reduced
* Hepatic function and blood flow
* GI absorption, GI bleed risk
* Baroreceptor sensitivity reduced
* Reduced first pass metabolism
* Protein binding?
* Receptor expression level changes
* Psychotropic drugs and extra pyramidal effects
35
**Whenever you prescribe a drug ensure:**
* That the correct agent is prescribed for the correct patient with the correct diagnosis.
* Check for drug allergies.
* Check for potential interactions with other drugs (prescribed and over the counter).
* Use generic drug names and write the drug in CAPITALS.
* Don't use abbreviations.
* Ensure that the dose, frequency and times, and route of administration are clearly identified. Include a start date (and a review/end date if appropriate).
* Be cautious using decimal points; these may be difficult to read resulting in 10x the dose.
* Write ‘Units’ rather than ‘u’ as the latter can be misread as ‘0’; again 10x the dose.
* Print name as well as signing if on a paper chart
* Always make sure you review medications on a daily basis and stop medications which are not needed.
36
which tool used to support medication review
STOPP-START
37
STOPP-START tool
Old people are known to have increased risk of adverse effects with medication due to age related alteration in pharmacokinetics and pharmacodynamics
* When to stop and start drugs
* Screening tool first introduced and validated in 2008
* Brought together expertise including geriatricians and clinical pharmacists
* For use in older patients **≥65** (use some judgment)
* Many trusts/ regions have their own adapted documents which may have local nuances
* **In conjunction with your clinical judgement**
38
STOPP-START aims to
* **Aim to highlight and prevent inappropriate prescribing → reduction in DDIs and or ADRs**
39
example of STOPP-START
* Anticholinergic effects (burden)
* Antipsychotics
* Alzheimer’s medication
* Other side effects
* Drowsiness
* Lowering BP
* Lowering blood glucose
* Balancing risk and benefits
