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MD3001 > End of Life Care > Flashcards

End of Life Care Flashcards

1
Q

Define palliative care.

A

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness
through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

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2
Q

Distinguish between the old and newer concepts of end of life care.

A

OLD CONCEPT
Curative care takes the majority of the care. Once it has been established that nothing can be done (at the very end), palliative care takes over.

NEW CONCEPT
At the beginning of end of life care it’s mainly disease modifying/potentially curative but also a little palliative. As the illness progresses, the use of palliative care increases whilst the use of curative care deceases. Towards the end (before death), bereavement care also begins to prepare the patient for death. Bereavement care continues even after death to help relatives cope.

Refer to slide 6 in lecture on “End of Life Care”

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3
Q

Define end of life.

A

 Those facing imminent death (i.e. less than 12 months) & those with:
– Advanced, progressive, incurable conditions
– General frailty (likely to die in 12 months)
– At risk of dying from sudden crisis of condition
– Life threatening conditions caused by sudden catastrophic events

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4
Q

Give examples of non-cancer diseases which require palliation of symptoms.

A

End-stage Cardiac failure
End- stage COPD
Motor Neurone disease
Advanced renal disease etc.

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5
Q

What are the aims of palliative care ?

A
  • Treat the person as a whole (as well as care for those that matter to them)
  • Address quality of life, including good symptom control
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6
Q

Give examples of principles of good end of life care.

A
  • Open lines of communication
  • Anticipating care needs and encouraging discussion
  • Effective multidisciplinary team input
  • Symptom control – physical and psycho-spiritual
  • Preparing for death - patient & family
  • Providing support for relatives both before and after death
  • An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.
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7
Q

Distinguish between general and specialist end of life care.

A

GENERAL: Integral part of the routine
care delivered by all health and social care professionals to those living with a progressive and incurable disease, whether at home, in a care home, or in hospital

SPECIALIST: Same principles as general end of life care, but can help people with more complex palliative care needs (patient has preference to die in hospice setting)

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8
Q

Give examples of some of the different roles in the multidisciplinary team in charge of end of life care.

A
  • Specialist nurses (community, hospice, other)
  • Palliative care doctors
  • GP
  • Secondary care (non-palliative teams)
  • District nurses
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9
Q

Give examples of adjunct therapies which can be given in addition to actual treatment.

A
  • Music
  • Gentle Touch
  • Pet
  • Aromatherapy
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10
Q

Identify some physical symptoms common to most terminal illnesses.

A 
 Pain
 Dyspnoea
 Nausea / vomiting
 Anorexia / weight loss
 Constipation
 Fatigue
 Cough
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11
Q

Explain the role of psycho-spiritual distress in end of life care. What is its role

A

Exacerbates physical symptoms.

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12
Q

What are possible causes of psycho-social distress in end of life care patients ?

A

– Uncontrolled physical symptoms
– Alcohol / drug withdrawal
– Depression
– Other medical causes e.g. hyperthyroidism

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13
Q

Define Advance and anticipatory care planning.

A

Ongoing process of discussion between the patient, those close to themselves and their care providers, focusing on that person’s wishes and preferences for the future. It is perhaps best defined as an umbrella term potentially covering a number of planning processes, including legal, personal, and clinical.

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14
Q

What should be discussed as part of advance and anticipatory care planning ?

A
  • Wishes/preferences/fears about care
  • Feelings/beliefs/values that may influence future choices
  • Who should be involved in decision making ? (I.e. Who)
  • Emergency interventions (e.g. CPR)
  • Preferred place of care (i.e. Where)
  • Religious/spiritual/other personal support
  • May wish to make an Advance & Anticipatory care plan/formalise wishes regarding care
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15
Q

What are different ways to formalize a patients wishes in end of life care ?

A

1) Advance Statement
2) Advance Direction
3) Power of Attorney

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16
Q

Define advance statement.

A

A statement that sets down your preferences, wishes, beliefs and values regarding your future care (not legally binding)

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17
Q

Define advance decision.

A

A decision you can make now to refuse specifics treatments in the future (can be legally binding).

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18
Q

What are other terms used to talk about Advance Decisions ?

A

Advance Direction to Refuse Treatment (ADRT)
Advance Refusal of Treatment
Living Will

19
Q

Give an example of advance & anticipatory care planning relevant to the clinical component of such planning.

A

Having morphine and midazolam available at home with the patient just in case.

20
Q

Define power of attorney.

A

legal document that allows someone to make decisions for you, or act on your behalf, if you’re no longer able to or if you no longer want to make your own decisions.

21
Q

What weight does an advance statement have in determining care once the patient has lost competence ?

A

Request will be given weight but future decisions can’t be bound by their statement (i.e. treatment must be of overall benefit to patient)

22
Q

What are possible forms of treatment a patient might be refusing through an advance decision ?

A

Life sustaining treatment such as ventilation, DNACPR

23
Q

What are factors which must be considered to ensure the validity of the advance direction ?

A
  • Is it clearly applicable?
  • When was it made?
  • Did the patient have capacity when it was made?
  • Was it an informed decision?
  • Were there any undue influences when made?
  • Has the decision been withdrawn?
  • Are more recent actions / decisions inconsistent?
24
Q

Identify legislation relevant to the validity of advance decisions.

A

• ‘Mental Capacity’ Act, 2005 (England and Wales)
– Specific sections within Act covering ADRT

• ‘Adults with Incapacity ’Act (Scotland), 2000
– No specific framework for Advance Decisions in Scotland, but must comply with the Act (i.e. in determining what, if any, intervention is to be made, account shall be taken of past and present wishes and feelings of the adult)

25
Q

What are pros of advance directions ?

A
  • Enhances autonomy
  • May encourage / improve discussions on end-of-life decisions
  • Avoid breaching patient’s personal / religious beliefs
  • Death with dignity
26
Q

What are cons of advance directions ?

A
  • May not be valid
  • May not be applicable
  • Attitudes may change with onset of serious illness
  • May have been advances in medicine since being made
27
Q

Define Gold Standards Framework (GSF).

A

Systematic, evidence based approach to optimising care for all patients approaching the end of life, delivered by generalist frontline care providers.

28
Q

Who is the gold standards framework aimed towards ?

A

– For people considered to be at any stage in the final years of life;
– For people with any condition or diagnosis
– For people in any setting, in whichever bed they are in
– Provided by anyone in health or social care
– At any time needed

29
Q

What is “‘More Care: Less Pathway” ?

A

Independent review into Liverpool Care Pathway (LCP) in July 2013.

30
Q

What are the findings of the “More Care: Less Pathway” review into the Liverpool Care Pathway ?

A

– Where used properly, many people died
peaceful, dignified deaths
– But…in many cases it was associated with poor experiences of care

31
Q

What was the response to the findings in the “More Care: Less Pathway” review ?

A

– ‘One chance to get it right’- guidance document setting out 5 priorities for care of dying people
– ‘Care for people in the last days and hours of life’ guidance document

32
Q

What are the 5 priorities for care of dying people in the guidance document of the same name ?

A

1) The possibility that a person may die within the next few days or hours is recognised and communicated clearly, decisions made and actions taken in accordance with the person’s needs and wishes, and these are regularly reviewed and decisions revised accordingly.
2) Sensitive communication takes place between staff and the dying person, and those identified as important to them.
3) The dying person, and those identified as important to them, are involved in decisions about treatment and care to the extent that the dying person wants.
4) The needs of families and others identified as important to the dying person are actively explored, respected and met as far as possible.
5) An individual plan of care, which includes food and drink, symptom control and psychological, social and spiritual support, is agreed, coordinated and delivered with compassion.

33
Q

Identify the principles listed in the ‘Care for people in the last days and hours of life’ guidance.

A
  • Principle 1: Informative, timely and sensitive communication is an essential component of each individual person’s care
  • Principle 2: Significant decisions about a person’s care, including diagnosing dying, are made on the basis of multi- disciplinary discussion
  • Principle 3: Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed as far as is possible
  • Principle 4: Consideration is given to the wellbeing of relatives or carers attending the person
34
Q

Define the WHO pain ladder.

A

(Inexpensive) framework for providing symptomatic pain relief. Three-step approach:

  1. Non-opioids (e.g. aspirin, paracetamol, NSAID) ± adjuvant
  2. Weak opioids (for mild to moderate pain, e.g. codeine) ± adjuvant ± non-opioid
  3. Strong opioids (for moderate to severe pain, e.g. morphine) ± adjuvant ± non-opioid

Climbing up a step every time pain persists or increases.

35
Q

How effective is the WHO pain ladder ?

A

70 to 90%

36
Q

What is the preferred route of administration of the drugs as part of the WHO pain ladder ?

A

Oral route for all

37
Q

What is the time frame of cancer pain analgesics ?

A

Cancer pain is continuous - analgesics should be given at regular intervals (i.e. by the clock), not on demand

38
Q

What are the adjuvants used in the WHO cancer pain ladder ?

A

Drugs to help calm fears and anxiety

39
Q

What is involved in care following the patient’s death ?

A
  • Support for the family

- Communicating with all those involved (e.g. GP, district nurses)

40
Q

What professionals are involved in supporting the families after the death of the patient ?

A

– Chaplain
– Counsellors
– Family workers
– Health care professionals

41
Q

What step of care before the death of the patient makes it easier to support the family after the death of the patient ?

A

Establishing a relationship with the family during end of life care helps facilitate support after patient’s death

42
Q

What are the criteria for death ?

A

The simultaneous and irreversible onset of apnoea (i.e. no respiratory effort, no breath sounds) and unconsciousness in the absence of the circulation, observed and confirmed for a minimum of 5 minutes.

• After five minutes of continued cardiorespiratory arrest confirm:

  • absence of pupillary responses to light
  • absence of the corneal reflexes
  • absence of any motor response to supra-orbital pressure
43
Q

How does recognition of death occur in primary care, and in hospital ?

A

•In primary care absence of mechanical cardiac function is normally confirmed by:

  • Absence of a central pulse
  • Absence of heart sounds

•In hospital can be supplemented by one or more of:

  • Asystole on a continuous ECG
  • Absence of pulsatile flow using direct intra-arterial pressure monitoring
  • Absence of contractile activity using echo

MD3001 (75 decks)

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