Living with Dying - Tutorial 5

Question 1

Historically, in what setting did death normally occur in?

Answer 1

Institutional setting

Question 2

What accounted for 1 in 3 deaths in the mid 19th century?

Answer 2

Infectious disease

Question 3

What are the most common causes of death now?

Answer 3

Cancer and IHD

Since 1995 cancer has outstripped IHF

Question 4

In the young, what percentage of deaths are accounted for by accidents?

Answer 4

38% of deaths in boys

23% of deaths in girls

Question 5

What is the main cause of death in men aged 15-34?

Answer 5

Suicide

Question 6

Since 1861, what has the life expectancy in Scotland increased by?

Answer 6

32.3 years for men and 34.1 years for women

Question 7

What are the effects of unexpected death?

Answer 7

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 press coverage
Deaths of children carry an even more profound sense of shock e.g. SIDS has no definite diagnosis and may carry the stigma of parental blame

Question 8

What is the last phase of care when a patient’s condition is deteriorating and death is close?

Answer 8

Terminal care

Often misleadingly only associated with cancer

Question 9

What is a more helpful term for the management of conditions until the terminal phase is reached?

Answer 9

Palliative care

Question 10

What is palliative care?

Answer 10

A philosophy of care that emphasises quality of life

Performed by a MDT - communication between members is essential

Question 11

Where is most palliative care provided?

Answer 11

Most provided in primary care with support from specialist practitioners and specialist palliative care units (or hospices)
GPs can act as companions for patients undergoing palliative care

Question 12

The WHO state that palliative care

Answer 12

improves the quality of life of patients and families who face life-threatening illness, by providing pain and symptom relief, spirit and psychosocial support.. from diagnosis to the end of life and bereavement

Question 13

In 2008, the Scottish Government developed a national action plan for palliative and end of life care, what is this called?

Answer 13

Living and Dying Well

Question 14

Living and Dying well states that “palliative care is not just about care in the last months, days and hours of a person’s life, but about

Answer 14

ensuring quality of life for both patients and families at every stage of the disease process from diagnosis onwards… palliative care focuses on the person, not the disease and applies a holistic approach to meeting the physical, practical, functional, social, emotional and spiritual needs of patients and carers facing progressive illness and bereavement”

Question 15

What does palliative care encompass?

Answer 15

End of life care, regardless of cause of illness

Question 16

What are doctors encouraged to do in relation to palliative care?

Answer 16

Consider which patients would benefit from palliative planning and treatment from early on in their illness

Question 17

What are the benefits of identifying early which patients are likely to need palliative care?

Answer 17

Can discuss patient’s wishes with them and try where possible to care for them where they want to be treated and in a way that they want to be treated

Question 18

What is the ‘Supportive and Palliative Care Indicators Tool’?

Answer 18

A guide for doctors to consider their patients who have a life-limiting diagnosis e.g. 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

Question 19

What does supportive and palliative care start with?

Answer 19

Anticipatory care planning

Question 20

What are some things to consider in supportive and palliative care planning?

Answer 20

Where does the patient want to be cared for
Does the patient want to be resuscitated in the event of a 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

Question 21

What is done once the patient is on the palliative care register?

Answer 21

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 MDT present, to ensure that everyone is aware of how the patient is

The patient will be reviewed regularly

Question 22

What can be used to evaluate how quickly the situation is changing for the patient and to see if their care needs re-evaluated?

Answer 22

The Palliative Performance Scale

Question 23

How are PPS scores determined?

Answer 23

By reading horizontally at each level to find a best fit for the patient who is then assigned as the PPS % score

Question 24

What are some uses of PPS?

Answer 24

Excellent communication tool for quickly describing patient’s current functional level
May have value in criteria for workload assessment or other measurements and comparisons
Appears to have prognostic value

Question 25

What are the benefits of palliative care in primary care?

Answer 25

Ensures practice have a register of palliative patients Ensures that the team meet regularly to discuss the cases Enhances communication between team members Out of hours also notified of palliative cases

Question 26

What are the features of managing symptoms in palliative care?

Answer 26

Pain is often feared by patients No symptoms should be ignored e.g. anxiety, insomnia and nausea may all be significant and distressing symptoms It is important to respond globally to the patient and his or her family

Question 27

According to the WHO, what are the features of palliative care?

Answer 27

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 patient's illness and in their own bereavement Uses a team approach to address the needs of patients and their families, including bereavement counselling if indicated

Question 28

What are some professionals that might be involved in palliative care?

Answer 28

``` Primary care team Macmillan nurses CLAN Marie Curie nurses Religious or cultural groups ```

Question 29

What have been described as elements of a good death in Western culture?

Answer 29

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 a personal growth - acceptance and moving on Death according to personal preference and in a manner that resonates with the person's individuality

Question 30

Most people express the preference for a home death, what percentage of people achieve this?

Answer 30

26%

Question 31

What framework offers tools to enable primary care to provide palliative care at home?

Answer 31

The Gold Standards Framework These include setting up a cancer register, reviewing these patients and reflective practice

Question 32

What are the stages of breaking bad news?

Answer 32

``` 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 ```

Question 33

What are the potential reactions to bad news?

Answer 33

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

Question 34

When is it useful to consider the stages of adjustment in grief, as described by Parkes?

Answer 34

When dealing with a bereavement and when a patient is given bad news or a life-limiting diagnosis

Question 35

What are the features of grief?

Answer 35

Individual experience 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

Question 36

What percentage of deaths occur in hospices?

Answer 36

15-20%

Question 37

What is euthanasia?

Answer 37

Has come to mean the deliberate ending of a persons life with or without their request

Question 38

What is voluntary euthanasia?

Answer 38

Patient's request

Question 39

What is non-voluntary euthanasia?

Answer 39

No request

Question 40

What is physician assisted suicide?

Answer 40

Physician provides the means and the advice for suicide

Question 41

Why do people request euthanasia?

Answer 41

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

Question 42

How should you respond to a patient requesting euthanasia?

Answer 42

``` 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 ```