Palliative careJo Swallow and Mary Valentine

GP Educators.F2 teaching session Sept 2012.

Understand the role of every clinician in End of Life care

Introduction to symptom management at the end of life.

Awareness of the Gold standards Framework for the dying patient

Appreciate impact of DNAR Practice Communication skills in end of life

care

Objectives

What percentage of the population die every year?

A) 1% B) 5% C) 0.1%

Mortality rate

End of Life Care is important. • 1% population die/year- mainly

elderly non-cancer patients. • Too few people die at home or their

place of choice. • Hospital admissions and deaths are

expensive and may be preventable - care must be brought closer to home.

• Everyone is involved in end of life care - most care is from the GP.

It affects us all

The Long Walk Home….

Hearing the Bad News…

Your experiences

Think of a time when you have been involved: yourself, your family or friends…. Or caring for someone personally or professionally….

Write the story….

Hearing the Bad News…

Common themes?

Hearing the Bad News…

Tips/Frameworks which you’ve come across/use.

Hearing the Bad News…

SETTING PERCEPTION INVITATION KNOWLEDGE EMPATHY STRATEGY AND SUMMARY

Breaking bad news frameworks? SPIKES

Advance Preparation Build a therapeutic envionment/relationship Communicate well Deal with the patient and family reactions Encourage and validate emotions

Breaking bad news frameworks… ABCDE

Mr J L B Maketoni….

Someone that did it well…

Identification: we’re often the first person to suspect the severity of the illness

Informing and explaining: we are often the one who has to tell them or explain/translate or reinforce what “the hospital says”

Continuity and coordination: we are the patient’s advocate and involved at all stages with the patient and their family.

How do GP’s fit in?

The Gold Standards Framework is all about putting systems in place, taking a systematic approach to care.

There are seven C's, (key tasks)

How do GP’s fit in?

Communication Coordination Control of symptoms Continuity and cross boundary working Continued learning Carer support Care in dying phase

How do you identify someone who is going to die in the community?

The sensitivity of the surprise question "No" response was 75% and the specificity was 90%. Conclusions:

The surprise question is a simple, feasible, and effective tool to identify patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning.

Would I be surprised if this patient died in the next year?

How do you feel about this being broached?

Advanced planning: DNR..

 

Do Not Resuscitate (DNR) forms vs Allow Natural Death (AND) forms,

Many hospices have a policy that they do not carry out CPR and patients have to "opt in" rather than "opt out" of resuscitation

Ultimately it is the doctor's decision whether or not it is in the patient's best interests for a resuscitation attempt to be made - doctors do not have to provide anything they perceive to be a futile treatment.

Advanced planning

 

If relatives are offered "resuscitation" many will opt for this. However, if the success statistics, relative distress, morbidity and inpatient stays associated with CPR are discussed, many patients will not wish to undergo this intervention

paramedics will attempt CPR on a patient who undergoes cardiopulmonary arrest in an ambulance

Information to be recorded clearly in the notes

Advanced planning

Quiz in pairs/groups of 3.

Control of symptoms

Pain Nausea and vomiting Intestinal obstruction Breathlessness Cough Haemoptysis Respiratory tract secretions Spinal cord compression Superior vena cava obstruction Hypercalcaemia Management of the last few days of life Terminal restlessness and agitation Use of steroids Miscellaneous problems Indications for the use of a syringe driver in palliative care

Control of symptoms-15 tripwires

15 min exercise

www.helpthehospices.org.uk/clip/pdf/hpp-1.pdf

Helping the patient with pain

A worried wife.

Consultation practice, in 3’s pt, dr and observer.

What are the barriers? How do patients feel? How do we feel?

Feedback, Talking to patients about terminal illness

Stages of bereavement:Denial Anger Bargaining Depression Acceptance

Elisabeth Kubler-Ross.

Bereavement

It is quite normal not to ‘feel’ anything following a death; people often have a delayed reaction.

Some people don’t deal with their emotions for days, months or even years after the death.

Many people feel angry about death they can feel guilty about being angry – it is normal to feel a sense of injustice.

Understanding responses….

Understand the role of every clinician in End of Life care

Introduction to symptom management at the end of life.

Awareness of the Gold standards Framework for the dying patient

Appreciate impact of DNAR Practice Communication skills in end of life

care

Revisiting Objectives

Questions?