End of Life Care Dr Anne Garry Consultant in Palliative Medicine
Concerns voiced both by public and professionals.. Implementation and on-going training highly variable across country Decisions made by junior doctors without senior reviews Many examples of poor communication with patient and family Was the problem the document or the way in which it was used..?
Neuberger review (1) Recommendation Avoid term pathway Clarity about definition End of life vs last days of life Clear communication about the diagnosis of dying and decision making around it Clarity over need for consent and explanation Adjust language to support patients with hydration and nutrition Discussion with family about the use of medication and syringe drivers Action Care plan Care plan for the last days of life First section is focussed on decision making and who/ how this is communicated Space to document explanation around significant decisions Increase guidance in plan for staff completing Increased guidance for staff
Neuberger review (2) Recommendation All patient must have a named senior clinician responsible for their care Daily medical review required Avoid making significant decisions out of hours unless unavoidable Action Signature required at decision making section Countersignature required if training doctor (ST3 or above) has signed on behalf of consultant or GP Consultants/GPs to have made a plan of care
The future NICE clinical guideline on care of dying adults in 2015 There will be not be a national document CQC-themed inspections with a focus on end of life care in all care settings Revise the Priorities in light of any new research evidence and feedback once it is implemented
Care plan for lasts days of life Incorporates recommendations More care less pathway Leadership Alliance One chance to get it right
Cross care setting Read the document
Leaflets
3 Sections 1. Decision making (Doctor s section) 2. Care plan (mainly nurses) 3. Care after death 4. Symptom control section will be stand alone in version 2
Section 1(Doctors) Decision making process guide Familiarise yourself with the decision making process
Consult algorithm Recognise patient may be dying Reverse the reversible
Communication and capacity Has the patient got Capacity Advance care plan ADRT Lasting power of attorney Preferred place of death Agreed contacts
Deciding patient in last days of life Discuss significant issues DNACPR Hydration and nutrition Interventions Medications Rationalise Anticipatory medications Syringe driver Family concerns and what is course of event Document
Decision made Date and GP signature required If training doctor ST3 or GPVTS above countersignature required by GP or consultant
Initial assessment (GP to complete) Explained the diminished need for hydration, and that fluids are not necessary at this time. Will review daily. No interventions required No artificial nutrition given at present. Would not benefit the patient at present to commence at this time. Medication has been rationalised. Statins and asprin discontinued. Has a DNACPR form. Discussed with patient and family that CPR would not be suitable for Alan. They agree. Syringe driver not required at present but spoke to family about its appropriateness if needed.
Section 2 Care Plan Starts after decision is made in section 1.
Initial assessment (Nurse) Complete initial assessment and sign when pages 11,12, 14 completed
Assessments A to R (Nurse) Alan in pain Given morphine 3mg sc Alan now settled; 14:00 S.Smith SS
Ongoing assessment Day 2 to 3 Day 4+: separate continuation pages
White space sheets Write any relevant conversations
Section 3: Care after death More relevant in community hospital and units
Section 4 Symptom Control Introduction Mouth care Diabetes Pain Nausea & Vomiting Respiratory secretions Dyspnoea Opioid conversion chart
Section 4 Principles of Symptom Management Worth reading
Diabetes in last days of life
Pain control
New Syringe driver chart Hospital and community use 12 page booklet Introduction Anticipatory medication Regular medication Syringe driver prescription 1 to 4 Checklist Opioid conversion chart
Introduction Read the instructions before using the chart
Anticipatory medication Read this section Usually only need to prescribe 4 key drugs
PRN opioids MORPHINE 3mg 14/10/14 A C Garry 14/10/14 A C Garry Opioid section needs populating NB in renal failure use OxyNorm sc Alfentanil sc 14/10/14 A C Garry 14/10/14 A C Garry
Antiemetics 14/10/14 14/10/14 Antiemetic information 4 drugs Haloperidol Cyclizine Metoclopramide Levomepromazine A C Garry A C Garry 14/10/14 A C Garry 14/10/14 A C Garry
Anti agitation Use Midazolam Occasionally levomepromazine Rarely Phenobarbitone 14/10/14 14/10/14 A C Garry A C Garry 14/10/14 A C Garry 14/10/14 A C Garry
Respiratory secretions Use Midazolam Occasionally levomepromazine Rarely Phenobarbitone 14/10/14 14/10/14 A C Garry A C Garry 14/10/14 A C Garry 14/10/14 A C Garry
Extra PRN chart
Regular medication X 2 FENTANYL Patch Why this section? Opioid patches Mouth care products Need to know about opioid patches for calculating PRN doses In last days of life Keep opioid patch in situ Remember patch will need changing Negotiate with patient/ relative or nurse who will change the patch
Syringe driver prescription MORPHINE 10mg (TEN) MIDAZOLAM 10mg HALOPERIDOL 1mg Consent Water for injection 14/10/14 A C Garry If 2 or more drugs are mixed together the combination is unlicensed. Prescriber needs to sign for the unlicensed preparation
Syringe driver prescription MORPHINE 10mg (TEN) MIDAZOLAM 10mg HALOPERIDOL 1mg ACG 15/10/14 Water for injection 14/10/14 A C Garry MORPHINE 20mg (TWENTY) MIDAZOLAM 15mg HALOPERIDOL 1mg Water for injection 15/10/14 A C Garry Cancel and sign prescription No 1 and rewrite new prescription No 2
Set up and checklist x 6 (Nurse) 2 Set up Complete shaded and white area checklist Monitoring Complete white area
Opioid conversion chart
Correct use of opioids Refer to Nice guidance of opioids in palliative care Lots of errors recently Avoid decimal points, if posssible Opioid routes Do not circle all routes as oral, sc, im, iv not same dose equivalent If opioid dose altered a new prescription is required Words and figures for doses above 10mg morphine
Opioid conversions PRN is 1/6 th of total daily dose Oral morphine to sc morphine divide by 2 Oral morphine to oral oxycodone divide by 2 oral oxycodone to sc oxycodone divide by 2 Fentanyl 25microgram/hr = 90mg oral morphine over 24 hours
Opioids and driving Please warn patients about opioids and driving when starting or increasing doses. This information is sometimes omitted when patient start opioids in hospital Opioid leaflet available
Drugs and driving blood concentration limits to be set for certain controlled drugs Cannabis Cocaine Morphine Diamorphine Mathadone Ketamine Amphetamine Flunitrazepma Clonazepam Diazepam Lorazepam Oxazepam Temazepam
DNACPR Cross care setting form version 13
DNACPR Version 13 the only valid form Patient information leaflet available On disharge Carbonated copy stays in medical notes Original goes home with patient Use a red bordered envelope to send original form home with patient CQC visit Inspect validity of form NOK details Countersignature required if form not signed by a consultant Have you spoken to patient or family re DNACPR decision? DNACPR decision must be documented in the notes? Everyones responsibility to check forms are correctly filled in DNACPR presentation on learning hub
AMBER care bundle Used in patients where life expectancy is about 2 months Assessment Management Best practice Engagement with patients and relatives Recovery is uncertain
Amber care bundle
Advance care planning PPC preferred place of care ADRT Advance decision to refuse treatment
Resources Yorkshire and Humber palliative care symptom control guidance York palliative care formulary (being updated) Syringe driver chart Hospital + PRN charts with anticipatory drugs Community Conversion charts, spider and table Care plan for last days of life
Thank you for listening Any questions Would it be helpful having some of these resources on an app?