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Dr Harriet Preston
Palliative Medicine Consultant
March 2019
People Centred
Positive
Compassion
Excellence
End of Life Care
Aims & Objectives
• Palliative care services at BVH
• Amber Care Bundle
• Recognising the dying phase
• DNACPR
• PPD & Rapid Discharge Pathway
• Prescribing at the end of life
• Better the Letter
People Centred
Positive
Compassion
Excellence
What is Palliative Care? • The aim of palliative care is to improve the quality
of life for patients and their loved ones.
• This includes symptom management, psychological and social support for patients at any stage of a life limiting illness, and those important to them
• We also deliver education and empower staff to deliver excellence in end of life care within the trust.
People Centred
Positive
Compassion
Excellence
Why are we needed? • >50% of all deaths in England occur in hospital • The majority of these deaths are expected • Approx 1/3 inpatients are in their last year of life • Typically 80 % of care home residents • People in their last year of life
– have on average 2-3 hospital admissions – Can spend up to 1 month in hospital
• “It is morally wrong to waste a dying person’s time”
People Centred
Positive
Compassion
Excellence
Palliative care at BVH
• 2 Consultants - Dr Preston & Dr Whitfield
• 6 Trinity Clinical Nurse Specialists
• 3 Trinity Associate Clinical Nurse specialists
• Mon-Friday 8-5pm
• Out of Hours - Trinity Hospice telephone advice line
People Centred
Positive
Compassion
Excellence
Referral criteria • Any patient with a life limiting illness:
• complex unstable symptoms • complex end of life care needs • complex ethical decisions • complex fast track discharge to facilitate a home death • advance care planning discussions • complex psychological needs of the patient or family/carer
• Please inform the patient/relatives first!!!!!!
People Centred
Positive
Compassion
Excellence
AMBER Care Bundle • Developed by Guys & St Thomas’ 2010
• Systematic approach to manage the care of patients who
facing an uncertain recovery and who are at risk of dying
• Designed to fit within any care pathway or diagnostic
group for patients whose recovery is uncertain.
• AMBER stands for: – Assessment
– Management
– Best practice
– Engagement
– Recovery uncertain
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
Amber Care Bundle
4 elements
• Talking to patient & family to convey concerns
about their condition and establish their W&P
• Deciding together how the person will be cared
for should their condition get worse
• Agreeing & documenting a medical plan
• Daily follow up to record any changes and
address any concerns that they or their
family may have.
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
DNACPR & The Law
• Who’s decision is it?
• Do we have to make decisions for all patients?
• What is the legal position regarding DNACPR decisions?
People Centred
Positive
Compassion
Excellence
DNACPR is a medical decision • Consultant/GP in charge of the patient’s care • Patients have the right to refuse treatments but
cannot demand them • Doctors cannot be forced to perform what they
believe to be inappropriate procedures • As doctors we have a LEGAL DUTY to involve
patients and relatives in decision-making unless it is likely to cause physical/psychological harm
• Patients have a right to a second opinion
People Centred
Positive
Compassion
Excellence
Joint Statement “When CPR has no realistic chance of success it is important to make decisions when they are needed, and not to delay a decision because a person is not well enough to have it explained to them or because their family or other representatives are not available; nevertheless a clear plan should be made to explain and discuss the decision with the person and/or their representatives at the earliest practicable opportunity”
• BMA, Resuscitation Council UK, RCN Oct 2014
Recognising the dying phase
People Centred
Positive
Compassion
Excellence
Reverse the reversible!
• Hypercalcaemia
• Renal failure
• Opiate toxicity
• Infection
• Intracranial – post-ictal
People Centred
Positive
Compassion
Excellence
The 3 triggers
• The Surprise Question
“Would you be surprised if this patient were
to die in the next few months/weeks/days?”
• General indicators
• Disease-specific clinical indicators
People Centred
Positive
Compassion
Excellence
General indicators of poor prognosis • Co-morbidity – biggest predictive indicator • Advancing disease burden • Decreasing reversibility/response to treatment • Progressive weight loss >10% in past 6 months • Serum Albumin <25g/l • Declining functional performance status • Increasing dependence in ADL’s • Sentinel event e.g., serious fall, move to NH • Unplanned/crisis admissions • Eligibility for DS1500
People Centred
Positive
Compassion
Excellence
Individualised Plan of Care for the Dying Person
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
PPC & PPD
People Centred
Positive
Compassion
Excellence
Rapid Discharge Pathway
• The aim of the rapid discharge for patients at end of life pathway is to facilitate a safe, smooth and seamless transition of care from hospital to community for patients with terminal illness who choose to be cared for in their preferred place of care for their last hours and days of life.
People Centred
Positive
Compassion
Excellence
Rapid Discharge Pathway • 4 Hour Discharge
– Patient has hours to days to live
– The patient is discharged from the hospital within 4 hours
• Fast-Track Discharge
– Patient has days to weeks to less than 4 weeks to live
– The patient is discharged from the hospital within 24 hours.
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
What would you send home with the patient?
People Centred
Positive
Compassion
Excellence
What do we prescribe for?
• Pain
• Nausea and vomiting
• Respiratory tract secretions
• Agitation or terminal restlessness
• Breathlessness
People Centred
Positive
Compassion
Excellence
JIC4CD’s - Just in case! • Prescription and authorisation for administration in a planned manner a
set of drugs that will cover most of the common symptoms at the end of life
• Can be prescribed for anyone who is diagnosed with a progressive life limiting illness who is thought to be approaching the last weeks/days of life
• They are prescribed at the lowest dose and in small quantities just in case symptoms develop
• They allow action to be taken before a more comprehensive management plan can be implemented
• Ideally planned and not an ‘emergency response’
People Centred
Positive
Compassion
Excellence
End of Life Anticipatory Drugs
• The prescription and authorisation of drugs already needed or expected to be needed soon in order to maintain symptom control in the last days of life
• Doses will depend on current medications
• May need a continuous subcutaneous infusion (CSCI) as well as PRN medications
• Do not come in a tamper proof sealed bag
• Prescribed in the standard way as take home medications
• Also prescribed in the SPAR booklet
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
SPAR booklet
• Subcutaneous ‘as required’ and Syringe Pump Prescription Administration Record
• An authorisation and administration record for:-
– Just in Case drugs
– End of Life Anticipatory drugs
– continuous subcutaneous infusions (CSCI)
People Centred
Positive
Compassion
Excellence
• Clear symptom control advice • Order of pre-printed drugs changed so that water
for injection first and should be signed for all • Prescription for JIC4CD’s separated from
anticipatory medications • Pink coloured pages for controlled drugs other
than core drugs e.g., oxycodone • Specific green coloured pages for medications to
be used under SPCT guidance e.g., octreotide
People Centred
Positive
Compassion
Excellence
Syringe drivers
• We do not prescribe syringe drivers ‘just in case’ for patients discharged from the trust unless they have been commenced on one as an inpatient
People Centred
Positive
Compassion
Excellence
Who else do we need to inform?
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
EPaCCs
• Electronic
• Palliative
• Care
• Co-ordination
• System
People Centred
Positive
Compassion
Excellence
EPaCCS enables the recording and sharing of people’s care
preferences and key details about their care at the end of life
People Centred
Positive
Compassion
Excellence
MIG Access – Clinical Hub
People Centred
Positive
Compassion
Excellence
MIG – EPaCCS Data
Where can you find additional guidance?
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
Clinical Practice Summary Guidance on consensus approaches to managing Palliative Care Symptoms North West Coast Strategic Clinical Network
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
People Centred
Positive
Compassion
Excellence
Any questions?
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