HEAD AND NECK STUDY DAY…. .A MULTI -DISCIPLINARY APPROACH

Advance Care Planning

Defining End of Life

People are “approaching the end of life” when they are likely to die within the next 12 months. This includes people whose death is imminent (expected within a few hours or days) and those with:

Advanced, progressive, incurable conditionsGeneral frailty and co-existing conditions that mean they

are expected to die within 12 monthsExisting conditions if they are at risk of dying from a

sudden acute crisis in their conditionLife-threatening acute conditions caused by sudden

catastrophic events.General Medical Council (2010)

Publications

In 2008 the DOH published The End of Life Care Strategy – the strategy aimed to improve the end of life care for all patients irrespective of diagnosis.

In 2014 the End of Life Care Strategy’s fourth annual reports’ focus was on supporting people to be cared for and to die in their place of choice, providing the community services to enable this to happen.

Enablers to improving end of life care

The National End of Life Care Programme (2012) published a guidance pack identifying five key enablers to assist healthcare providers in delivering high quality end of life care:

Advance Care PlanningElectronic Palliative Care Coordination Systems

(EPaCCS)The AMBER care bundleThe rapid discharge home to die pathwayThe Liverpool Care Pathway

Defining Advance Care Planning

Advance care planning (ACP) is a voluntary process of discussion about future care between an individual and their care providers, irrespective of discipline. If the individual wishes, their family and friends may be included. It is recommended that with the individual’s agreement this discussion is documented, regularly reviewed, and communicated to key persons involved in their care

www.endoflifecareforadults.nhs.uk

Advance Care planning

It is based on a person’s priorities, beliefs and values and involves taking time to learn about end-of-life care options and services before a health crisis occurs.

When one cannot express one’s own wishes, professional care providers (e.g. treating physician, other health care professionals) and/or other people (e.g. family members, spouse) are forced to take decisions during such as a crisis that may differ from the patient’s wishes.

Advance Care Planning

Can cover anything to do with future care including:

Thoughts on different treatments or types of careReligious or spiritual beliefs that wish to be

reflected in careName of a person to be consulted in the futureAppointing someone to make decisions when a

patient is no longer able to make decisions for themselves

Preferred place of care/death

When to Initiate a ACP Discussion

Usually takes place in anticipation of a future deterioration with loss of capacity whereby the patient is unable to make decisions and/or communicate their wishes Life changing eventFollowing a new diagnosis of life limiting

conditionSignificant shift in treatment focusMultiple hospital admissions

Opportunities

In oncology, many patients have a long disease trajectory, during which events can occur that may provide the opportunity to establish preferences.

In palliative care, many of these topics become more important and end-of-life issues should be discussed with the patient, to know what the patient wants in a specific situation.

Who Initiates the Discussion

Initiation of ACP discussion by a care provider requires careful consideration:Appropriate communication skillsFull knowledge of the person’s medical condition,

treatment options and social situationThere may be someone more appropriate to carry

out this discussion e.g. specialist nurseThe time and setting should be appropriate for a

private discussionMay require several discussions for clarification

and comprehension of relevant information.

Advance Care Planning

The discussion of advance care planning depends on many factors, such as cultural background, religion, legal framework, educational level, personality type, age, personal life-and-death experiences and disease status.

Where would you most like to

be cared for?

DNACPRDo you have any comments or wishes that you would like to share with

others?

Who else would you like to be

involved if it ever becomes difficult

to make decisions?

Organ donation

Have you made a

will?

Is there anything

you would ideally like

to avoid happening

to you?

Lasting Power of Attorney

Advance Decision to Refuse

Treatment (ADRT)Preferenc

es regarding

future care?

Benefits of Advance Care Planning

Can provide the comfort of having a greater sense of control over what may happen in the future

Promotes discussion around understanding of illness and prognosis

Can promote important discussions between family members

Provides valuable information about patient’s priorities which can be considered in the future when acting in the patient’s best interests

Identifies issues providing MDT with valuable information which may need to be considered when planning treatment

Can provide opportunity to discuss appointing LPA or ADRT.

Challenges to Advance Care Planning

Voluntary process and patient may not want to confront future issues.

Who is the most appropriate person to initiate the discussion?

Need to have appropriate communication skillsNeed knowledge of support, services and choices

available in particular circumstancesNeed adequate knowledge of the benefits, harms and

risks associated with treatments or refusal of treatments to allow patient to make informed choice

People change their minds.

Head and Neck Patient Considerations

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Artificial hydration and nutritionImplications of cancer treatmentsRisk of bleed

Mrs Tracey- the Verdict

Doctors will need to justify DNACPR decisions Keep an account of the discussions they have with

the patients and families involvedIf a patient has capacity there should be a

presumption that they should be involved in the DNACPR decision

There must be 'convincing' reasons not to involve the patient

A clinician's belief that cardio-pulmonary resuscitation will fail is not enough. Neither is the fact that the patient may find the topic distressing.

Decisions Relating to Cardiopulmonary Resuscitation

The guidelines identify the key ethical and legal issues that should inform all CPR decisions. Key points emphasized in the new guidance include:

The value of making anticipatory decisions about CPR as an integral part of good clinical practice

The importance of involving people (or their representatives if they are unable to make decisions for themselves) in the decision-making process

That when CPR has no realistic chance of success it is important to make decisions that are in the best interest of the patient, 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

The importance of careful documentation and effective communication of decisions about CPR.

Implications of Cancer Treatments

Altered airwayChanges to sensationSpeechSwallowingOral changes- trismus, dry mouthChanges to appearanceSurvivorship

Hydration and Nutrition

Support patients to consider when they may wish for an intervention

When they may wish for an intervention to be discontinued

Bleeding Risk- Head and Neck Cancers

SurgeryRadiotherapyPost Operative Healing ProblemsFungating TumourSystemic Factors

Carotid Artery Rupture

Royal United Hospital Bath 2013

Carotid Artery Rupture: Related to the Terminal Care of the Head and Neck Cancer Patient: Policy, Procedure & Guidelines

Use of Benzodiazipines

The dose should be given as 5mgs IV stat dose or 5-10mgs SC/ IM stat dose. (Smith, 1992; Pereira & Phan, 2004)

The dose may then be titrated until the patient is fully sedated (Forbes, 1997)

Opioid Use During Massive Haemorrhage

Morphine is not recommended as a first line medication in this event for the following reasons:Supporting literature and anecdotal accounts of

witnesses to this event, there are no reports of pain.Due to the strict protocols on the storing, drawing

up of, and administering of, controlled drugs, there may be unavoidable delays when administering the morphine.

There are connotations with euthanasia and ethical dilemmas raised by the administering of an opioid if the patient is in no pain.

Use of opioid

Therefore, it is not recommended in this event EXCEPT for the following reasons:Should the patient have a bleed that is not likely

to result in immediate death and complain of PAIN and/or BREATHLESSNESS, then these would be the only indications to give morphine

orShould the patient be on regular opioids, the dose

given should be equivalent to their usual four hourly dose of opioid. In an opioid naïve patient, 2.5mg of morphine could be given subcutaneously

Managing the risk

The goal of management of the event must be to minimise anxiety, ease suffering and ensure death with dignity providing a calm, reassuring and caring atmosphere.

Thank you for you time ……..any questions