Week 11: Palliative care Flashcards
What is palliative care?
“The active holistic care of patients with advanced, progressive illness. Management of pain and other symptoms and provision ofpsychological, social and spiritual support are paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Many aspects of palliative care are also applicable earlier in the course of the illness in conjunction with other treatments.”
aims of palliative care
- To affirm life but regard dying as a normal process.
- To provide relief from pain and other distressing symptoms.
- To neither hasten nor postpone death.
- To integrate psychological and spiritual aspects into mainstream patient care.
- To provide support to enable patients to live as actively as possible until death.
- To offer support to the family during the patient’s illness and in their bereavement.
Examples of diseases which
- Cancer
- Dementia
- Frailty
- Pain management
- Ischaemic heart disease
- COPD/ PF
patients are ‘approaching the end of life’ when they are
likely to die within the next 12 months. This includes patients whose death is imminent (expected within a few hours or days) and those with:
- advanced, progressive, incurable conditions.
- general frailty and co-existing conditions that mean they are expected to die within 12 months.
- existing conditions if they are at risk of dying from a sudden acute crisis in their condition
- life-threatening acute conditions caused by sudden catastrophic events.
This guidance also applies to those extremely premature neonates whose prospects for survival are known to be very poor, and to patients who are diagnosed as being in a persistent vegetative state (PVS), for whom a decision to withdraw treatment may lead to their death.
Clues a person may be approaching the end of their life
-
Pattern recognition
- It can be useful to ask yourself: ‘Would you be surprised if this patient were to die in the next few months, weeks, days?’
-
Deterioration in their underlying condition(s)
- You may notice that symptoms of their specific illness(es) are worsening: for example, a person with liver failure may develop ascites; a person with lung cancer, COPD or heart failure may become more breathless; a person with a brain tumour may have more frequent seizures.
- Common symptoms in patients with advanced illness
-
Exacerbations may become worse or more frequent
- COPD
- HF (may not make it back to baseline after exacerbation)
Common symptoms in patients with advanced illness
- Loss of appetite (anorexia)
- Reduced food and fluid intake
- Loss of weight
- Tiredness and fatigue
- Physical weakness
- Pain
- Struggling with self-care
- Loss of continence
- Low mood
- Constipation
- Insomnia
Ethical issues in end-of-life care
- Most challenging decisions are about withdrawing or not starting treatment when it has the potential to prolong life
- E.g. giving antibiotics
- CPR
- Renal dialysis
- Artificial nutrition and hydration
- Mechanical ventilation
- In some cases these interventions may only prolong dying and cause unnecessary distress
- Widely agreed that high quality treatment and care towards the end of life includes palliative care (should be provided at any stage in the progression of patients illness)
- Managing pain
- Managing distressing symptoms
- Psychological, social and spiritual support
Key principles of end-of life-care
- Presumption in favour of prolonging life
- Decisions concerning potentially life-prolonging treatment must not be motivated by a desire to bring about pt death i.e. take all reasonable steps to prolong life
- Treat end-of-life patients with the same quality of care as other patients
- Dignity
- Respect
- Compassion
- Work on the presumption that every adult has capacity to make decisions
- If pt lacks capacity then decisions must be made in the best interest of the patient
key ethical principles
advance care planning
is important because it can inform healthcare decisions such that a patents goals based on their personal values, beliefs and wishes are respected. Improves pt and family interaction. Important ACP discussion is early in pt disease as patients may need time to process information and still has capacity
ReSPECT process
- Recommended Summary Plan for Emergency Care and Treatment
- A process of discussion between patients, families/carers and professionals, which allows a decision to be made in an emergency situation where they do not have capacity / communication to make that decision.
- Discussion use to develop a sharded understanding of a patients’ conditions, circumstances and future outlook
- Also exploring preferences for care and treatment
- From these agreed clinical references are agreed and documented on the ReSPECT form
- Explore patients preferences
ReSPECT forms are for
- adults, paediatrics and neonates
- specifically useful for people who are at risk of emergency treatment
are ReSPECT forsm legally binding?
Not legally binding
- ReSPECT is not a DNAR
- guide to provide a recommendation for immediate decision making
palliative care medication
morphine also used for breathlessness i.e. in COPD (oxygen is not used for comfort but to prevent organ hypoxia)
what makes us feel like vomiting
when the chemoreceptor trigger zone is activated
what triggers the CTZ
direct triggers
visceral afferents from gut
vestibular nuclei
sensory afferents via midbrain
