palliative care the months, the weeks, the days.anticipatory medications supplied carer needs...
TRANSCRIPT
Palliative Care
the months, the weeks,
the days.
Christina Sharkey
Macmillan GP Facilitator
Verification of death
Update OOH
Bereavement support
needs assessed and
agreed. Referral
made for further
support if appropriate.
Audit of pathway
completed
Learning reviewed in
MDT
GSF initiated
Carer needs
assessment fast-
tracked
OOH
Prognosis
communicated
Keyworker nominated
Discussion of ACP
inc. ADRT, PPC
initiated
EOLC plan for dying
patient initiated
OOH update
ACP inc. ADRT, PPC
reviewed
Fast track to
Continuing Care
completed if
additional service
funding required
Anticipatory
medications supplied
Carer needs reviewed
Support arranged for
provision of terminal
care in setting of
patient’s choice e.g.
Hospice at Home
DS1500 completed
DNAR status
reviewed and
communicated
OOH, 111 informed of
ACP via Special
Patient Note
Respite care
arranged if
appropriate
Blue Badge
application fast-
tracked if applicable
24 hour access to advice and co-ordination of care underpin
the pathway
Prognosis < 1 year Prognosis < 6
months Prognosis “a few
weeks” Prognosis < 1 week After death
The following will be provided at the appropriate time according to individual patient and carer needs:
Specialist care (condition-specific and/or palliative)
Specialist psychological support Self-help and support services
Respite care Equipment
Spiritual support
End of Life Care Pathway – Details of care provision
Case
Monica 64 yr
Breast carcinoma with bony
metastases
Lives with husband John
3 children
Under oncology
Surgery, radiotherapy and
chemotherapy
Receive OPD letter
• Will not be offered further chemotherapy
Triggers
Triggers
Triggers
Prognosis < 1 year
Less than a year
GSF initiated
Carer needs assessment fast-
tracked
OOH
Prognosis communicated
Keyworker nominated
Discussion of ACP inc. ADRT,
PPC initiated
Special Patient Note
Diagnosis
Preferred Place of Care
Main carer
Medication/Syringe Pump
DN team
DNACPR
Anticipatory Meds
Fast tracked
Final days
Electronic Palliative Care Coordination System
(EPaCCS)
Advance Care Planning
Entirely voluntary process
Puts patient in control, enabling
choice
Advance
care planning
Advance
Statement
of
wishes and
preferences
Advance
Decisions
to Refuse
Treatment
Lasting power
of attorney
Less than 6 months
DS1500 completed
Do Not Attempt to Resuscitate status
reviewed and communicated
Out Of Hours
Respite care arranged if appropriate
Blue Badge application fast-tracked if
applicable
Prognosis < 6
months
Monica
Readmitted with headaches and vomiting, had radiotherapy for brain metastases
‘If you became ill again I would be afraid of not knowing what kind of care you would like could we talk about this?’
She says to you she would like to be cared for at home now, no more admissions to hospital she understands that she may be reaching the end of her life.
Symptoms are stable now you think her prognosis is months
Advance Statement
Verbal or written
Must be made when patient has
capacity
Record of individuals wishes, feelings,
values, beliefs
NOT legally binding
However once patient loses capacity
you are legally bound to take into
account when make best interests
decision
Monica
Has a daughter Marie, she lives 2 miles away and visits every week, helps with cleaning, shopping
What would happen if you became ill again and could not talk to your doctor about your treatment? ‘Who will make decisions for you?
‘Marie’s always been very sensible she’d know what I would want if I couldn’t tell you’
Lasting Power of Attorney
Made when patient has capacity
LPA
• Property/affairs
• Personal welfare
Personal welfare LPA
• Can only act when patient loses capacity to make decisions
• Can only make life sustaining decisions if have
specific authorisation
www.direct.gov.uk
Office of public guardian: 0300 456 0300
Monica
Begins vomiting again, bloods
checked, hypercalcaemia
Admitted for bisphosphonate IV
Recurring problem, attending OPD
regularly for IV treatment
Overall becoming more fatigued,
shorter time between IV treatments
‘Had enough’ does not want anymore
IV treatment
Advance Decisions to Refuse
Treatment
Person whilst still capable, 18 and over
Verbal or written
Refuse a specific medical treatment
In particular circumstances
When they may lack capacity to consent to or refuse that treatment
Legally binding if valid and applicable to the circumstances
Advanced Decisions to Refuse
Treatment
If refusing potentially life sustaining treatment must be
Written
Contain statement ‘even if my life is at risk’
Signed
Witnessed
Communicate and record distribution
Monica
She doesn’t mention CPR however
you think it would be sensible to see if
she wishes to talk about this.
Cardiopulmonary Decision
Making Algorithm
www.emas.nhs.uk
Is cardiac or
respiratory
arrest a clear
possibility in the
circumstances
of the patient?
No No
Ye
s
It may not be possible to make an advanced CPR decision if you
cannot anticipate what you would write on the death certificate if the
patient arrested. If you cannot anticipate an arrest you cannot
consent for or obtain refusal of CPR since any arrest will be
unexpected.
Consequences:
The patient should be given opportunities to receive information or
an explanation about any aspect of their treatment. If the individual
wishes, this may include information about CPR treatment and its
likely success in different circumstances.
Continue to communicate progress to the patient (and to the
partner/family if the patient agrees). Continue to elicit the concerns
of the patient, partner or family.
Review regularly to check if circumstances have changed
In the event of an unexpected arrest: carry out CPR treatment if there is
a reasonable possibility of success (if in doubt, start CPR and call for
help).
Is there a
realistic
chance that
CPR could be
successful?
No
Yes
It is likely that the patient is going to die naturally because of an
irreversible condition. Where a decision not to attempt CPR is made on
these clear medical grounds, it is not appropriate to ask the patient’s
wishes about CPR (or those close to the patient where the patient lacks
capacity), but careful consideration should be given to whether to inform
the patient of the decision.
Consequences:
Document the fact that CPR treatment will not benefit the patient, e.g.
‘The clinical team is as certain as it can be that CPR treatment cannot
benefit the patient in the event of a cardiac or respiratory arrest due to
advanced cancer, so DNACPR (Do Not Attempt CPR).
Continue to communicate progress to the patient (and to the
partner/family if the patient agrees or if the patient lacks capacity). This
explanation may include information as to why CPR treatment is not an
option (as described above) and include; ‘Unfortunately CPR will not
work in your circumstances and we need to ensure all others know about
this decision to ensure your comfort at the end of your life, if that is OK?’
Continue to elicit the concerns of the patient, partner and family.
Review regularly to check if circumstances have changed
To ensure a comfortable and natural death effective supportive care
should be in place, with access if necessary to specialist palliative care,
and with support for the family and partner.
If a second opinion is requested, this request should be respected,
whenever possible.
In the event of the expected death, AND (Allow natural Dying) with effective
supportive or palliative care in place.
YE
S
Does the
patient lack
capacity?
N
o
Yes
In adults : is there an Advance Decision to Refuse
Treatment (ADRT) refusing CPR, or a signed Welfare
Attorney order (with its accompanying 3rd party
certificate) with the authority to decide on serious
medical conditions- the most recent order takes
precedence. Otherwise make a decision in the patient’s best
interests, following the processes stipulated by law, e.g. the
Mental Capacity Act
Are the potential
risks and
burdens of CPR
considered
greater than the
likely benefits of
CPR?
N
o
CPR should be
attempted
When there is only a very small chance of success and
there are questions whether the burdens outweigh the
benefits of attempting CPR: the involvement of the patient
(or, if the patient lacks capacity, an ADRT, Lasting Power of
Attorney as above or those contributing to Best Interests) in
making the decision is crucial. When patients have mental
capacity their own view should be the primary guide to
decision-making. In cases of doubt or disagreement, a
second opinion should be requested.
Yes
Y
E
S
www.emas.nhs.uk
Monica
You visit Monica weekly and you now
see a deterioration each week.
In bed most of time now, sleeping
more
Eating less
A Few Weeks
ACP inc. ADRT, PPC,DNACPR reviewed
Fast track to Continuing Care
completed if additional service funding
required
Anticipatory medications supplied
Carer needs reviewed
Support arranged for provision of
terminal care in setting of patient’s
choice e.g. Hospice at Home
Prognosis
“a few weeks”
Core 4
Anticipatory Medication DNS1
AP
Monica
Monica is now confined to bed.
Awake for short periods of time
She is unable to take oral medication
Managing only sips of fluid
Days
Personal Palliative Care Plan for
the Dying
Out Of Hours, updated on patient’s
condition
Prognosis < 1 week
Leadership Alliance for the
Care of Dying People
Acknowledge the possibility of death
Communicate this, attention to patient needs and wishes
Sensitive communication
To patient and those important to them
Decisions about treatment and care
Involve patient and those important to them
Needs of family and those important to patient
Actively explore,
Individual care plan
Food and drink
Symptom control
Psychological, social, spiritual support
Opioids
Conversion Calculation
24h dose/2
Morphine PO to morphine SC
Morphine PO to diamorphine SC 24h dose/3
Oxycodone PO to oxycodone SC 24h dose/2
Patches in Terminal Phase
Do not start fentanyl/buprenorphine patches
in terminal phase however if already in
place:
Leave patch on
Breakthrough doses of morphine
subcutaneously (see pocketbook)
If ≥ 2 breakthrough doses required/24hr give
morphine by syringe driver starting with sum
of breakthrough doses in preceding 24hrs
Agitation and Delirium
Breathlessness
Nausea and Vomiting
Pain
Respiratory Tract Secretions
Monica
Monica has
1 x 6.25mg prns levomepromazine for agitation
1 x 20mg prn for hyoscine butylbromide and 40mg put in pump with next change
Symptoms settle
She dies at home with her husband and children around her.
After death
Verification of death
Special Patient Note Updated
Bereavement support needs
assessed and agreed. Referral
made for further support if
appropriate
Learning reviewed in
Multidisciplinary Team
After death