the months, the weeks, the days. Christina Sharkey Macmillan GP - - PowerPoint PPT Presentation

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

• f

wishes and preferences Advance Decisions to Refuse Treatment Lasting power

• f attorney

http://www.ncpc.org.uk as a PDF

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

• ver

 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

• f 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

• f 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

• ption (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

• 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

• 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

• f 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