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What is one of the most fundamental duties of a doctor? 

Care of the dying


What are the most common causes of death today? 

Cancer and Ischaemic heart disease


Give some epidemiology relating to death: 

  •  In the young, accidents account for 38% of deaths in boys and 23% in girls.
  •  In men age 15-34 suicide is the main cause.
  •  In Scotland the life expectancy has increased by 32.3 years for men and 34.1 years for women since 1861.


What are some of the repercussions of an unexpected death? 

  •  Causes a profound sense of shock. No chance to say goodbye, or take back hasty words.
  •  Accidents might be compounded by multiple deaths, legal involvement or even press coverage.
  •  Deaths of children carry an even more profound sense of shock. SIDS (sudden infant death syndrome) has no definite diagnosis and may carry the stigma of parental blame. 


What do the FOPC team have to say about expected death? 

  •  Terminal care is the last phase of care when a patients condition is deteriorating and death is close.
  •  It is often misleadingly only associated with cancer.
  •  Palliative care is a more helpful term for the management of conditions until the terminal phase is reached.


What is palliative care, who is involved and what makes a successful palliative team? 

  •  A philosophy of care that emphasises quality of life.
  •  Is performed by a multi disciplinary team.
  •  Communication between members is essential.
  •  Most provided in primary care with support from specialist practitioners and specialist palliative care units (or hospices).
  •  GP’s can act as companions on a journey for patients undergoing palliative care.


What is the old vs new concepts of palliation? 


How do you know if a patient is at a Palliative Stage?

The 'Supportive and Palliative Care Indicators Tool' (figure 1), is a guide for doctors to consider their patients who have a life-limiting diagnosis (eg. Cancer), or a worsening chronic condition (e.g. COPD), and highlight if they are at a stage where supportive and palliative care should take place. This starts with 'Anticipatory Care Planning', planning with the patient and their Carers what they want for their future care.

 Where do they want to be cared for? Do they want to be resuscitated in the event of cardiac arrest? Or do they want to be allowed to die naturally? Who do they want to be informed of their care and any changes in their condition? Are they fully aware of their prognosis? Is their family aware of their prognosis? Once a patient has been diagnosed as at a palliative stage of care, and these discussions have taken place, the patient should be placed on the practice's Palliative Care Register.

Once on the Palliative Care Register, the plan for the patient should be sent to the Out of Hours service so that anyone who may be involved in the patient’s care is aware of the patient’s wishes. The practice will have regular palliative care meetings to discuss the patients on the palliative care register, with the Multi- disciplinary team present, to ensure that everyone is aware of how the patient is. The patient will also be reviewed regularly. The Palliative Performance Scale can be used to evaluate how quickly the situation is changing for the patient and see if their care needs re-evaluated.


What are some of the roles of palliation in primary care? 

  •  Practices have a register of palliative patients.
  •  The practice  team meet regularly to discuss the cases.
  •  Enhances communication between team members.
  •  OOH also notified of palliative cases.


What is the WHO definition of Palliative care? 

  •  Provides relief from pain and other distressing symptoms
  •  Affirms life and regards dying as a normal process
  •  Intends neither to hasten nor postpone death
  •  Integrates the psychological and spiritual aspects of patient care
  •  Offers a support system to help patients live as actively as possible until death
  •  Offers a support system to help the family cope during the patients illness and in their own bereavement.
  •  Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated.


What are some of the wider team that are involved with palliative care? 

 These could include Macmillan Nurses, CLAN, Marie Curie Nurses, Religious or Cultural Groups amongst other support networks.


What are descriptions of a 'good death'? 

  • Pain-free death
  • Open acknowledgement of the imminence of death
  • Death at home surrounded by family and friends
  • An 'aware' death, in which personal conflicts and unfinished business are resolved
  • Death as personal growth
  • Death according to personal preference and in a manner that resonates with the person's individuality


What is the common preferred place of care? 

  • Most people express the preference for a home death.
  • Only 26% achieve this.
  • Most of the final year is spent at home however.
  • The Gold Standards Framework offers  tools to enable primary care to provide palliative care at home.
  • These include setting up a cancer register, reviewing these patients and reflective practice (eg SEA’s)


What are 8 steps to breaking bad news? 

  •  Listen
  •  Set the Scene
  •  Find out what the patient understands
  •  Find out how much the patient wants to know
  •  Share information using a common language
  •  Review and summarise
  •  Allow opportunities for questions
  •  Agree follow up and support


What are the stages of adjustment in grief described by Parkes? 

  •  Shock
  •  Anger
  •  Denial
  •  Bargaining
  •  Relief
  •  Sadness
  •  Fear
  •  Guilt
  •  Anxiety
  •  Distress


What does the FOPC team have to say about grief? 

  • Is an individual experience
  • Is a process that may take months or years
  • Patients may need to be reassured that they are normal
  • Abnormal or distorted reactions may need more help
  • Bereavement is associated with morbidity and mortality


What are notable features of hospices? 

  •  15-20% of deaths occur here depending on the area.
  •  Form part of the multidisciplinary care team.
  •  Are generally underfunded.


What is the meaning of euthanasia? 

  • Means ‘gentle’ or ‘easy’ death
  • Has now come to mean the deliberate ending of a persons life with or without their request


Explain the meaning's of the below: 

Voluntary euthanasia

Non-voluntary euthanasia

Physician assisted suicide

  • Voluntary Euthanasia – patients request
  • Non Voluntary Euthanasia – no request
  • Physician assisted suicide – Physician provides the means and the advice for suicide.


What is the legal position of euthanasia in the UK? 

  • Illegal in the UK
  • Ongoing national debate.
  • In 1994 House of Lords recommended no change.
  • In the Netherlands the law changed in the late 1990’s to allow euthanasia under certain circumstances


Why do people request euthanasia?

  • Less researched than the ethical arguments for and against.
  • Perhaps 3-8% of patients with advanced disease will ask to die.
  • The most common reasons are unrelieved symptoms or the dread of further suffering.
  • Some studies indicate that 60% of patients requesting euthanasia are depressed.


How can respond to a request for euthanasia? 

  •  Listen
  •  Acknowledge the issue
  •  Explore the reasons for the request
  •  Explore ways of giving more control to the patient
  •  Look for treatable problems
  •  Remember spiritual issues
  •  Admit powerlessness