Palliation

Question 1

Definition of:

• Palliative care
• Hospice based care
• Best supportive
• EOL care

Answer 1

Definition of:

• Palliative care: the active total care of patients whose disease is not responsive to curative treatment. It involves controlling pain and symptoms and includes social, psychological and spiritual problems
• Hospice based care: focuses on the care (of which illness is classed as terminal to death), comfort and qol of a person with a serious illness who is approaching eol. It looks after their medical, emotional, social, practical, psychological and spiritual needs and needs of family - holistic care. Can be inpatient or day patient.
  Doctors, nurses, HCAs, social workers, therapists, chaplains, volunteers, physio, OT
• Best supportive care: when a cure is not achieveable with existing treatments so management of physical and psychological symptoms and SE from diagnosis to post treatment care
• EOL care: patients who are likely to die within the next 12 months. Early identification leads to earlier planning and better coordinated care

Question 2

GMC guidance on treatment and care towards EOL -

Answer 2

Principles:

1. Equalities and human rights
2. Presumption in favour of prolonging life but no absolute obligation (assessing overall benefit of treatment)
3. Presumption of capacity - doctor explains situation + treatment options and explains overall benefit. They can also withdraw treatment. If making unwise decisions can do a best interest medical decision. If lacks capacity decisions made based on overall benefit + least restrictive to patients future choices option. ADRT/powers of attorney come in only when pt has lost capacity
4. Maximising capacity to make decisions
5. Overall benefit:

also
4. Advance care planning
5. Cardiopul resus
6. Care after death and organ donation

Question 3

Who is involved in palliative care team (9)

Answer 3

GP - prescribe meds + help manage symptoms
District nurse - organises care at home
Pharmacist
HCA - washing + dress, moving around, taking meds
Social workers - deliver meals, adapt home, help with washing/dressing/meals/ support carers
Clinical nurse specialist - help with questions, put in touch with diff services
Occupational therapist - equipment
Physio
Hospice care - nursing, emotional/practical support

Question 4

Palliative care with active disease management

Answer 4

Early integration of palliative care improves patient outcomes

Question 5

Signs suggesting a person is dying (9)

Answer 5

• bedbound
• drowsy/ reduced consciousness/ impaired cognition
• difficulty taking oral meds: switch to non oral route if med still has benefit
• reduced food / fluid intake: discuss risks of aspiration if still wish to eat. Offer good mouthcare. Assess daily rehydration status. Can give CAH as may relieve symptoms but can cause other problems and no evidence it prolongs life
• N+V
• increased symptom burden: may be more difficult in last few days as many meds/routes are unlicensed and effectiveness needs to be assessed individually
• shallow breathing: cheyne stokes resp pattern, use of accessory muscles, resp secretions (reposition)
• skin colour changes + temp changes at extremities
• decreased urine output/ incontinence

Question 6

Anticipatory prescribing:

• Definition
• Pain
• N+V
• Breathlessness
• Restless/ aggitation
• Resp tract secretions

Answer 6

Anticipatory prescribing:

• Pain: morphine 2.5-5 mg sc prn 1 hrly (when converting from oral -> sc divide total dose by 2)
• N+V: levomepromazine 2.5-5 mg sc prn 4 hrly
• Breathlessness: morphine 2.5-5 mg
• Restless/ agitation: midazolam 2.5-5 mg sc prn 1 hrly, if delirium/psychosis levomepromazine 6.25-12.5 mg sc prn
• Resp tract secretions: glycopyronium 200-400mg sc prn 4 hrly (max 1.2mg in 24 hours)

Use lowest effective dose, reduce opiate dose if esrf, frail, low birth weight. Stop meds that have no benefit

Question 7

Most common causes of death

Answer 7

• Frailty / comorbidity / dementia - slow decline + difficult to predict
• Organ failure - sudden crises / hospital admissions and each time decreasing recovery
• Cancer - rapid decline
• Sudden unexpected death

Question 8

The GSF prognostic indicator

Answer 8

1. If advanced illness/ progressive condition - would you be surprised in died in next few months? Pull together clinic, cormorb, social and other factors
2. Indicators of decline and decreasing needs - decreasing activity? Comorb? Advanced disease? Decreasing response to treatments? Repeated admissions? Sentinel event (fall, bereavement), weight loss? Serum albumin<25?
3. Specific clinical indicators - for cancer: (mets? Performance status 4? (if over 50% time in bed prognosis <3 months)

Question 9

Demonstrate understanding of:

• Mental capacity act
• Advanced decisions to refuse treatment
• Lasting power of attorney

Answer 9

Demonstrate understanding of:

• Mental capacity act: protects and empowers people over 16 who lack mental capacity (dementia, learning disability, mental health condition, unconscious, injury) covering decisions about daily things or life changing decisions like whether to have a surgery. Wherever possible help them make their own decisions, if someone else makes decision needs to be in their best interests
  e.g. if someone refuses further treatment ask if they know benefits of treatment, risks of not having treatment
• Advanced decisions to refuse treatment: must be in writing, signed, witnessed and stated clearly that decision applies even if life is at risk. >18 who are capable for when they lack capacity in future. Need to pass mental health act.
  This is different to a respect form which can go home. Focuses on patients wishes on their care which might be considered in emergencies
• Lasting power of attorney: another person enabled to make decisions about your health - can only refuse treatment of their behalf. >18. Attorney only has right when person looses capacity. However takes around 20 weeks in court.

Question 10

Ethical dilemmas in people with advanced cancer

Answer 10

Conflicts of information:

• Adaptive denial (using denial to improve wellbeing)
• Conspiracy of silence (an agreement to say nothing about an issue that should be known)
• Discrepancies: discussing pointless treatment, rejecting treatment, withdrawing life support measures
• Unrealistic expectations about the outcome of clinical trails
• Request for euthanasia or medically assisted suicide
• Beliefs - prayer
• Mistrust

Hence solved via gold standard framework:
- Identify need of palliation
- Assess needs/symptoms
- Plan care

• Autonomy - patient has the right to choose or refuse the treatment
• Beneficence - a doctor should act in the best interest of the patient
• Non-maleficence - first, do no harm
• Justice - it concerns the distribution of health resources equitably.
• Dignity - the patient and the persons treating the patient have the right to dignity
• Truthfulness and honesty - the concept of informed consent and truth telling