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Clinical Care Year 3 > End Of Life > Flashcards

End Of Life Flashcards

1
Q

Liverpool care pathway

A

Recognising that a person was dying was not always supported by an experienced clinician and not reliably reviewed
The dying person may have been unduly sedated as a result of too much medication
Perception that hydration and some medication may have been withheld or withdrawn

Was not direct consequence of pathway but often happened because of poor training, poor supervision

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2
Q

Ambitions for palliative and end of life care 2015-2020

A 
Each person is seen as individual 
Each person gets fair access to care 
Maximising comfort and wellbeing 
Care is coordinated 
All staff are prepared to care 
Each community is prepared to help
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3
Q

Leadership alliance for the care of dying people 2014

A

5 priorities for care:

  • Possibility that a person may die in coming days is recognised and communicated clearly, decision made in accordance with the persons need and wishes
  • Sensitive communication takes place between staff, person dying and family
  • dying person and family are involved in decisions and treatments
  • family is listened to
  • care is tailored specifically and delivered with compassion
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4
Q

Department of health - our commitment to you and end of life care 2016

A 
3 main areas - 
Treat the patient with dignity 
All care to be compassionate 
Reflect on care delivered 
5 key aims 
- aims to give a good death 
- live well until you die 
- informed choices 
- personalised care plans 
- respect patient wishes
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5
Q

NICE guidelines (NG31) - care of dying adult

A

Recognise when people are entering the last few days of life
Communicating and shared decision making
Clinically assisted hydration
Medicines for managing pain, breathlessness, agitation, nausea
Anticipatory prescribing

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6
Q

The route to success in end of life care - achieving quality in ambulance service 2012 GSF

A
  • GSF is a systemic evidence based approach to optimising care for people in last year of life with any condition in any setting
  • outlines a process to help clinicians
  • tools for flagging people who have increased care needs
  • identification, right through to discharge home or care in final days
  • has 7 steps (the 7cs)
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7
Q

7 C’s to gold standard framework

A 
Communication 
Coordination 
Control of symptoms 
Continuity of Care 
Continued learning 
Cared support 
Care in the dying phase
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8
Q

3 step process to GSF

A

Identify
- life expectancy 6-12 months
Assess
- clarification of patient needs and support required
- discuss goals and wishes
- recognised the patient is nearing end of life communicate with relevant teams
Plan
- crisis prevention allows patients to live well till death
- advanced care plan, dnacpr
-utilisation of community services

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9
Q

What is palliative care

A

An approach that improves the quality of life of patients and their families facing the problems associated with illness. Can be done through preventing and relief of suffering by means of early identification, assessment, treatment of pain and other problems

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10
Q

What is end of life

A

Likely to die within 12 months
Includes pt whose death is imminent
- advanced, progressive, incurable conditions
- general frailty and coexisting conditions expected to die within 12 months
- acute crisis of existing condition
- life threatening condition cause by catastrophic event

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11
Q

End of life vs palliative care

A

Palliative Care aims to decrease suffering with a condition, end of life is comfort care provided to those facing the end of their life

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12
Q

Signs of end of life patient

A 
Cold peripheries 
Altered breathing 
Temperature 
Confusion 
Incontinence 
Restlessness
Congestion 
Reduced urine output 
Increased sleep
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13
Q

Behaviours for end of life

A 
Pre planning 
Saying goodbye 
Communication change 
Hallucinations 
Behavioural changes
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14
Q

1-3 months signs and symptoms of end of life

A

Reduced appetite
Decreased fluid tolerance
Social withdrawal
Prolonged periods of rest and immobility

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15
Q

1-2 weeks signs and symptoms end of life

A 
Increased sleep 
Restlessness 
Increased confusion 
Hallucinations 
Physiological changes 
Complete intolerance for food 
Breathing more congested
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16
Q

1-7 days

A 
Hypotension 
Weak thready pulse 
Decreased responsiveness 
Increased restlessness 
Intermittent energy spells 
Glazed eyes 
Hands and feet may appear blotchy cold to touch 
Urine output decreased
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17
Q

Last minutes of life signs and symptoms

A

Patient no longer able to respond

Breathing pattern becomes gasping

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18
Q

Aims of palliative care

A
  • affirm life and regard dying as normal process
  • provide relief from pain and other symptoms
  • integrate psychological and spiritual aspects of patient care
  • offer a support system to help patient live as actively as possible till death
  • offer a support system for family
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19
Q

6 questions to ask end of life patient

A
  1. What is understanding of illness
  2. Are you receiving or due to receive any medical treatment ?
  3. Is there documentation/ other services involved?
  4. Would you want to manage at home
  5. What local services are available?
  6. What do we need to do next / tomorrow ?
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20
Q

What is anticipatory prescribing ?

A

They are just in case medications for cases such as breakthrough pain and get timely access to medications
Designed so drugs in patients home

Drugs should be clearly marked, and have means for recording administration
We do not do syringe driver

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21
Q

Dyspnoea in end of life

A

Severely impacted quality of life, often psychological. Discomfort may vary and may not be associated with hypoxia, tachypnea or Bradypnea
Listen to patient description

22
Q

Non-pharmacological management for dyspnoea

A

Positioning
Airflow - use fan or window
Relaxation, distraction, reassurance
Controller breathing technique

23
Q

Pharmacological treatment for dyspnoea

A

Opioids
Sensitivity of the respiratory centre to stimulation by carbon dioxide is reduced by morphine
Resp centre is area rich with opioid receptors

24
Q

Paramedic options

A

Oral, sc or IM morphine
Safety net ensure review by gp, district nurse, ooh, palliative care team
Anticipatory medication
Out of hours gp review

25
Q

Pain in end of life

A

Present with many patients, especially cancer. Patient may have breakout or breakthrough pain needs extra treatment

Pain scores, consider abbey pain scale, consider pain relief already taken, consider opiate naive or established, leave patches in situ, do not alter syringe drivers

26
Q

Myoclonic twitching and jerking

A

Not uncommon in dying patient and may reflect accumulation of excitatory opioid metabolites causing involuntary jerking

Common in renal failure

May be distressing for patients and their families, explain and phone for review or hospice help line

27
Q

Pharmacological interventions for pain

A

IM/SC morphine usually start 2.5-5mg if not on opiates. If Is already for breakthrough pain 1/6th of daily dose

Iv pain for bone pain

Caution below 90mmhg

28
Q

Factors to take into consideration when pharmacological interventions for pain in end of life

A 
Do not dilute the morphine 
Check previous administration 
4 hours for paracetamol, 6 hours if renal 
Effects of im/sc morphine 15-20 mins 
Paracetamol over 15 minutes 
Inform own gp or palliative team
29
Q

Terminal agitation/ restlessness in end of life

A

Normal at end of life important to treat
If not immediately dying try to reverse treatable factors
Irreversible can affect quality of life

NICE (NG31) provides guidance suggest to consider benzodiazepines such as Midazolam inform family this may cause to loc

30
Q

Moist and noisy secretions in end of life

A

Secretions may accumulate in the airway and resulting in gurgling and rattling
17 -57 hours before death
Reposition patient
Consider drug therapy - hyoscine bromide, hyoscine butylbromide- administer and record

31
Q

Nause and vomiting in end of life

A

Occurs in many patients
Recommended levomepromazine
May be another anti emetic
If giving JRCALC drug seek advice from palliative care team

32
Q

What is a palliative care emergency

A

Conditions which left untreated will seriously threaten the quality of life remaining. Reversibility needs to be considered in conjunction with patient wishes.

  • wishes of patient and family
  • nature of emergency
  • stage of illness and prognosis
  • comorbidities and symptoms
  • likely effectiveness of treatment
33
Q

What are reversible causes in end of life

A 
Infection 
Hypercalcaemia 
Medication changes 
Treatment consequences 
Palliative emergencies
34
Q

Palliative emergencies examples

A 
Metastatic spinal cord compression(mssc) 
Superior vena cava compression 
Neutropenic sepsis 
Pathological fractures 
Seizures 
Hypoglycaemia 
Drug toxicity 
Pain crisis 
Resp crisis 
Anaphylaxis
35
Q

What is metastatic spinal cord compression

A

Spinal cord compression due to direct pressure or collapse of the vertebral body due to spinal metastases result in vascular injury, cord necrosis and neurological injury

Occurs within any part of spine
Common in cancer especially lymphoma and myeloma

36
Q

Symptoms of metastatic spinal cord compression

A

Neurological signs (upper/lower/minor sensory/ asymmetric)
Pain - thoracic/cervical/ progress lumbar/ prevents sleep/ aggravated by straining sneezing/ localised spine tenderness/ radicular pain
Stiffness and weakness
Sensory loss
Urinary symptoms- retention/ incontinence

37
Q

What is radicular pain

A

Band pain round the body occurs in metastatic spinal cord compression

38
Q

Late symptoms of metastatic spinal cord compression

A

Peri-anal numbness and lack of anal tone
Not being able to open or control bladder or bowels
Priapism

39
Q

Management of metastatic spinal cord compression

A

Needs to be review urgently
Specialist treatment - involves administration steroids, will need neurological exam and mri
Treatment involves - radiotherapy/ surgery

Paramedic management - abcd problems, limit mobility, JRCALC pain management

40
Q

What is superior vena cava compression

A

Occlusion of the superior vena cava due to either external compression or internal obstruction
Most commonly caused by cancers
Severity of symptoms varies depending on degrees of obstruction

41
Q

Signs and symptoms of superior vena cava compression

A 
Venous distention in neck and chest 
Facial, neck swelling when lying down or bending over 
Proptosis (bulging eyes) 
Stridor 
Cough/ hoarseness 
Dyspnoea 
Headache 
Nasal congestion/ epistaxis 
Haemoptysis
42
Q

Management/ treatment options for Superior vena cava compression

A

Requires urgent management pathway
Manage symptoms e.g. give oxygen
Administer corticosteroids and diuretics where upper airway oedema decreased cardiac output and brain oedema is present

Sit the patient upright and elevate the head

43
Q

What is neutropenic sepsis

A

Potentially fatal complication of anti cancer treatment
These therapies to treat cancer can suppress the ability of bone marrow to respond to infection
Would suspect neutropenic sepsis in patients having anti cancer treatment who become unwell
Often occur between 7 and 12 days is when white blood cell at their lowest

44
Q

Signs and symptoms of neutropenic sepsis

A 
Temp more than 37.5 or less than 36 
Minor illness or feels unwell 
Tachypnoea 
Tachycardia 
Hypotension 
Chest pain 
Flu-like symptoms 
Gum or nose bleeds 
Vomiting 
Diarrhoea 
Bruising 
Catheter site infection (neutropenic patients are unable to produce pjs)
45
Q

Management and treatment for neutropenic sepsis

A

Manage according to JRCALC guidelines

All should be transported to hospital

46
Q

What is a respect form

A

It is a process that creates personalised recommendations for a persons clinical care in a future emergency

Must be a 2 way discussion between patient and healthcare professional, form must be kept with pt at all times

47
Q

Points to respect form

A 
Is proactive not reactive 
Is personalised 
Involves more than just 1 person 
About more than the cpr decision 
Applies nationally in all setting 
Has been developed by national experts and the public
48
Q

Key stages to the respect form

A
  1. Understand - establish a shared understanding of the person state of Health and medical conditions
  2. Set goals - to establish what is important to the person and what they see as main focus of their treatment
  3. Plan - to discuss treatments that should be considered as well as treatments which they may not want or may not help
49
Q

Relate respect form to other forms

A

ADRT - this is legally binding but respect form is not
ACP (anticipatory care plan) - other preferences such as funeral
End of life care plan - record a persons individual care and treatment leading up to death
CYPACP - childs advanced care plan

50
Q

Law and ethics of the respect form

A

The respect form is not legally binding they are designed to guide immediate decision making by health care professionals who to respond to people in crisis
Think best interest

51
Q

What’s should look for on respect form

A

Personal preferences priorities
2 boxes for clinical recommendations only one signed if both act best interest
Capacity
Clinical signature - makes it valid

Clinical Care Year 3 (18 decks)

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