ST1&2

PALLIATIVE CARE & ETHICS

Niall CameronRosalie DunnElayne Harris

Euan Paterson

Palliative Care and Ethics

09:00 Diagnosing dying / Anticipatory Care Planning

10:30 End of Life Ethics

11:45 Coffee / Tea

12:00 Symptom Relief in Palliative Care

12:45 Dining with death!

13:30 Do Not Attempt Cardio-Pulmonary Resuscitation – key issues & approach

14:45 Coffee / Tea

15:00 The ‘Good Death’

16:30 Feedback / Close

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!

Anticipatory Care Planning (ACP)

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

Which patients is it for?

‘Marla doesn’t have testicular cancer. Marla doesn’t have Tb. She isn’t dying. Okay in that brainy brain-food philosophy way, we’re all dying, but Marla isn’t dying the way Chloe is dying’

Chuck Palahniuk - Fight Club

Death

High

LowMany years

Function

Death

High

LowMonths or years

Function

Organ failure

6

Acute2

Dementia, frailty and decline

7

Death

High

LowWeeks to years

Function

5

Cancer

GP has 20deaths perlist of 2000patients peryear

Numbers and Trajectories

Diagnosing dying

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

• Would you be surprised…?

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???

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?

Legal Personal Medical

Potential Problems

Liverpool Care Pathway

ePCS / KIS

Welfare Power of Attorney

Advance Statement Thinking ahead & making plans

Anticipatory Care Planning

Just in Case

DNA CPRSPAR

DN Verification of Death

GSFS

Advance Care Planning

Continuing Power of Attorney

1 Statement of values2 Preferences & priorities3 Advance decision to refuse treatment4 Who else to consultGuardianship

Anticipatory Care Planning

SPARLanarkshire Home Care Pack

Legal

• Capacity– Welfare Power of Attorney– Continuing Power of Attorney– Guardianship

• Consent (ePCS / KIS)– To record– To transfer

• Advance decision to refuse treatment

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

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

The views and wishes of patient / carer

• ‘My thinking ahead and making plans’- What’s 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

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

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?

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 / KIS– Other communication

Which patients is ePCS / KIS 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???

What is ePCS / KIS for?

• Information transfer– ‘In Hours’ GP > OOH– Primary Care > A&E / Acute Receiving Units– Primary Care > Scottish Ambulance Service

• Prompts for proactive care• Anticipatory Care Planning • All data stored in one place• Structure for lists / meetings / etc• Palliative care DES

What does ePCS / KIS 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

What does ePCS / KIS 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…

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 / KIS)

• 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…