End of Life Care - bfwh.nhs.uk

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?