ST 2 PALLIATIVE CARE

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ST 2 PALLIATIVE CARE ETHICSwww.palliativecare
ggc.org.uk www.nhslanarkshire.org.uk/services/pal
liativecare/

• Niall Cameron
• Rosalie Dunn
• Elayne Harris
• Euan Paterson

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Palliative Care and Ethics

• 0900 Diagnosing dying / Anticipatory Care
  Planning
• 1015 Do Not Attempt Cardio-Pulmonary
  Resuscitation key issues approach
• 1100 Coffee / Tea
• 1115 End of Life Ethics
• 1230 Dining with death!
• 1330 Symptom Relief in Palliative Care
• 1445 Coffee / Tea
• 1500 The Good Death
• 1630 Feedback / Close

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Some all too common problems

• The sudden deterioration
• What does the patient know / think / want?
• What do the family know / think / want?
• Lack of medication
• Blue light 999 at end of life
• Who knows what?
• The weekend catastrophe
• The bad death
• and then 4 hours to confirm it happened!

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Anticipatory Care Planning (ACP)

• What is it?
• Why is it (possibly) more important in palliative
  care?
• Which patients is it for?

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Which patients is it for?

• Marla doesnt have testicular cancer. Marla
  doesnt have Tb. She isnt dying.
• Okay in that brainy brain-food philosophy way,
  were all dying, but Marla isnt dying the way
  Chloe is dying
• Chuck Palahniuk - Fight Club

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Numbers and Trajectories
GP has 20 deaths per list of 2000 patients
per year
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Diagnosing dying

• What primary disease do they suffer from?
• How are they at this moment?
• How rapidly are they changing?
• Would you be surprised?

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Which patients is it for?

• Patients with supportive / palliative care needs
• Whoever YOU feel should be included!
• Palliative care register
• GSF register
• SPICT / GSFS prognostication guidance?
• Chronic disease registers?
• Care Home patients??
• Housebound patients???

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Anticipatory Care Planning (ACP)

• What is it?
• Why is it (possibly) more important in palliative
  care?
• Which patients is it for?
• What does it entail?

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Anticipatory Care Planning
SPAR
Lanarkshire Home Care Pack
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Legal

• Capacity
• Welfare Power of Attorney
• Continuing Power of Attorney
• Guardianship
• Consent
• To record
• To transfer
• Advance decision to refuse treatment

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Clinical

• Consideration of potential problems
• What is likely to happen to THIS patient
• What might happen to THIS patient
• DNACPR
• Just in Case
• Proactive prescribing
• DN Verification of Expected Death
• Liverpool Care Pathway for the Dying
• Bereavement

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Patient / Personal

• Preferred priorities of care
• Place of care
• Place of death
• Admission?
• Aggressiveness of treatment
• What is wanted
• What is not wanted
• Who is to be involved

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The views and wishes of patient / carer

• My thinking ahead and making plans
• Whats important to me just now
• Planning ahead
• Looking after me well
• My concerns
• Other important things
• Things I want to know more about e.g. CPR
• Keeping track
• Developed from work by Professor Scott Murray
  Dr Kirsty Boyd, University of Edinburgh

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Advance statement

• Statement of values
• E.g. what makes life worth living
• What patient wishes
• E.g. place of care, aggressiveness of treatment
• What patient does not want
• E.g. PEG feeding, SC fluids, CPR
• Who they would wish consulted

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Anticipatory Care Planning (ACP)

• What is it?
• Why is it (possibly) more important in palliative
  care?
• Which patients is it for?
• What does it entail?
• What is the process?
• When should this be done?
• Who should do it?
• How should it be done?
• How should it be shared?

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ACP Process

• When should this be done?
• At any time in life that seems appropriate
• Continuously
• Who should do it?
• By anyone with an appropriate relationship!
• How should it be done?
• My Thinking Ahead Making Plans
• Carefully
• Write it down
• How can it be shared?
• ePCS
• Other communication

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What is ePCS for?

• Information transfer
• In Hours GP gt OOH
• Primary Care gt AE / Acute Receiving Units
• Primary Care gt Scottish Ambulance Service
• Prompts for proactive care
• Anticipatory Care Planning
• All data stored in one place
• Structure for lists / meetings / etc
• Palliative care DES

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What does ePCS contain?

• Information upload
• Palliative Care review date
• Consent to share information
• Current situation
• Diagnoses
• Key personnel involved
• Carer details
• Current treatment
• Repeat
• Last 30 days Acute
• Patient carer understanding
• Diagnosis Prognosis

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What does ePCS contain?

• Future Care Plan
• Patient wishes (VISION)
• Preferred Place of Care
• Resuscitation status
• Additional drugs in house (Just in Case)
• Advice for OOH GP e.g.
• Contact own GP OOH
• GP willingness to sign death certificate
• Additional OOH information (KEY section) e.g.
• Patient wishes
• Starting Liverpool Care Pathway
• Etc

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The ACP Checklist

• Capacity
• Power of Attorney / Possible future problems?
• Have we considered
• What is likely what might happen to this
  patient?
• Where the patient would like to be cared for?
• CPR / DNACPR?
• OOH information transfer (ePCS)
• Have we considered the possible need for
• Anticipatory prescribing (Just in Case)
• RN Verification of Expected Death
• The Liverpool Care Pathway for the Dying
• The patient / carer view
• My Thinking Ahead Making Plans

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DNACPR- Key Issues Approach
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DNACPR Key Issues

• Consider
• The fundamentals
• The framework
• The decision making process
• The patient / family view
• Legal aspects

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DNACPR Fundamentals

• The decision to offer CPR is a medical one
• Nothing to do with quality of life
• If CPR is likely to be futile do not offer it

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DNA CPR Framework

• Is the patient at risk of a cardiopulmonary
  arrest?
• Decision making
• CPR is unlikely to be successful due to
• The likely outcome of successful CPR would not be
  of overall benefit to the patient
• decided with patient
• decided with legally appointed...
• ...basis of overall benefit...
• CPR is not in accord with a valid advance
  healthcare directive/decision (living will) which
  is applicable to the current circumstances

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DNA CPR Decision making

• Is CPR realistically likely to succeed?
• What do we mean by success?
• Population that we are considering
• Facilities available
• People available

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CPR Decision

• What you think / what patient wants
• You think possible / patient doesnt want CPR
• Simple
• You think possible / patient wants CPR
• Complicated
• You think futile / patient doesnt want CPR
• Simple
• You think futile / patient wants CPR
• Complex

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DNACPR patient / family / legal issues

• Patient / family view is only relevant if CPR is
  a treatment option
• If success anticipated discussion needed
• If success not anticipated inform patient
• Relatives should not be asked to decide unless
  patient lacks capacity legally empowered to do
  so
• Communicate sensitively!

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DNACPR Approach

• Consider
• When you have done this
• What worked well?
• What didnt?!
• How to raise the subject
• When to raise the subject
• Practicalities

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Introducing the subject of DNACPR

• Communication
• Breaking bad news
• Narrowing the information / knowledge gap
• We know something we think they need to know!
• How much do they actually know?
• How much more, if any, do they want to know
• When do they want to know
• Who do they want to tell them

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The bad news

• What we feel we need to cover
• Whether CPR should be offered or not
• If futile patient / loved ones need to know
  this
• If not futile then we need to know what patient
  wants

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Getting CPR raised

• By patient and carer
• Spontaneously
• Prompted
• Another professional e.g. the hospital said
• My Thinking Ahead Making Plans

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Getting CPR raised

• By us (vague)
• How do you feel you are doing?
• Where would you like to be cared for?
• And if things got worse?
• How do you see the future?
• Are there any things youd like to avoid?
• Etc etc etc

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Getting CPR raised

• By us (more pushy)
• If youre really keen to be kept at home then
• What to do if there was a sudden change in your
  condition
• What to do if your heart was to stop

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CPR the subject matter

• General
• What it means
• Allow a natural death
• Likelihood of success
• Whether people would wish it
• Individual
• In your case
• Fine line
• Awareness raising, BUT
• Clinical decision has already been made

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What DNACPR is not about

• Anything other than CPR
• Any other treatments e.g. antibiotics
• Feeding
• Fluids
• Highlight everything else that we can still do

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Patient centred supportive care

• Whats the most important thing in your life
  right now?
• What helps you keep going?
• How do you see the future?
• What is your greatest worry or concern?
• Are there ever times when you feel down?
• If things get worse, where would you like to be
  cared for?
• Professor Scott Murray, University of Edinburgh

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DNA CPR Practicalities

• Completing the DNACPR form
• Where should form be kept
• When to update form
• Patient transfer

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DNA CPR Practicalities

• Communication
• Patients home
• Patient
• Family / loved ones
• OOH Services
• Scottish Ambulance Service
• Others?

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Discussion