the months, the weeks, the days. Christina Sharkey Macmillan GP - PowerPoint PPT Presentation

Palliative Care the months, the weeks, the days. Christina Sharkey Macmillan GP Facilitator

End of Life Care Pathway – Details of care provision After death Prognosis < 1 year Prognosis < 1 week Prognosis “a few Prognosis < 6 months weeks” GSF initiated DS1500 completed ACP inc. ADRT, PPC EOLC plan for dying Verification of death reviewed patient initiated DNAR status Update OOH Carer needs reviewed and Fast track to OOH update assessment fast- Bereavement support communicated Continuing Care tracked needs assessed and completed if OOH, 111 informed of agreed. Referral OOH additional service ACP via Special made for further funding required Prognosis Patient Note support if appropriate. communicated Anticipatory Respite care Audit of pathway medications supplied Keyworker nominated arranged if completed appropriate Carer needs reviewed Discussion of ACP Learning reviewed in inc. ADRT, PPC Blue Badge Support arranged for MDT initiated application fast- provision of terminal tracked if applicable care in setting of patient’s choice e.g. Hospice at Home The following will be provided at the appropriate time according to individual patient and carer needs: Specialist care (condition-specific and/or palliative) Specialist psychological support Self-help and support services Respite care Equipment Spiritual support 24 hour access to advice and co-ordination of care underpin the pathway

Case  Monica 64 yr  Breast carcinoma with bony metastases  Lives with husband John  3 children  Under oncology  Surgery, radiotherapy and chemotherapy  Receive OPD letter • Will not be offered further chemotherapy

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Less than a year GSF initiated Carer needs assessment fast- tracked Prognosis < 1 year OOH Prognosis communicated Keyworker nominated Discussion of ACP inc. ADRT, PPC initiated

Special Patient Note  Diagnosis  Preferred Place of Care  Main carer  Medication/Syringe Pump  DN team  DNACPR  Anticipatory Meds  Fast tracked  Final days

Electronic Palliative Care Coordination System (EPaCCS)

Advance Care Planning  Entirely voluntary process  Puts patient in control, enabling choice Advance care planning Advance Advance Statement Decisions Lasting power of to Refuse of attorney wishes and Treatment preferences

http://www.ncpc.org.uk as a PDF

Less than 6 months DS1500 completed Do Not Attempt to Resuscitate status reviewed and communicated Prognosis < 6 months Out Of Hours Respite care arranged if appropriate Blue Badge application fast-tracked if applicable

Monica Readmitted with headaches and vomiting,  had radiotherapy for brain metastases ‘If you became ill again I would be afraid of  not knowing what kind of care you would like could we talk about this?’ She says to you she would like to be cared  for at home now, no more admissions to hospital she understands that she may be reaching the end of her life. Symptoms are stable now you think her  prognosis is months

Advance Statement  Verbal or written  Must be made when patient has capacity  Record of individuals wishes, feelings, values, beliefs  NOT legally binding  However once patient loses capacity you are legally bound to take into account when make best interests decision

Monica  Has a daughter Marie, she lives 2 miles away and visits every week, helps with cleaning, shopping  What would happen if you became ill again and could not talk to your doctor about your treatment? ‘Who will make decisions for you?  ‘Marie’s always been very sensible she’d know what I would want if I couldn’t tell you’

Lasting Power of Attorney  Made when patient has capacity  LPA • Property/affairs • Personal welfare  Personal welfare LPA • Can only act when patient loses capacity to make decisions • Can only make life sustaining decisions if have specific authorisation  www.direct.gov.uk  Office of public guardian: 0300 456 0300

Monica  Begins vomiting again, bloods checked, hypercalcaemia  Admitted for bisphosphonate IV  Recurring problem, attending OPD regularly for IV treatment  Overall becoming more fatigued, shorter time between IV treatments  ‘Had enough’ does not want anymore IV treatment

Advance Decisions to Refuse Treatment  Person whilst still capable, 18 and over  Verbal or written  Refuse a specific medical treatment  In particular circumstances  When they may lack capacity to consent to or refuse that treatment  Legally binding if valid and applicable to the circumstances

Advanced Decisions to Refuse Treatment  If refusing potentially life sustaining treatment must be  Written  Contain statement ‘even if my life is at risk’  Signed  Witnessed  Communicate and record distribution

Monica  She doesn’t mention CPR however you think it would be sensible to see if she wishes to talk about this.

Cardiopulmonary Decision Making Algorithm www.emas.nhs.uk

It may not be possible to make an advanced CPR decision if you cannot anticipate what you would write on the death certificate if the patient arrested. If you cannot anticipate an arrest you cannot consent for or obtain refusal of CPR since any arrest will be unexpected. Consequences: Is cardiac or  The patient should be given opportunities to receive information or respiratory an explanation about any aspect of their treatment. If the individual arrest a clear No No wishes, this may include information about CPR treatment and its possibility in the likely success in different circumstances. circumstances  Continue to communicate progress to the patient (and to the of the patient? partner/family if the patient agrees). Continue to elicit the concerns of the patient, partner or family.  Review regularly to check if circumstances have changed Ye s In the event of an unexpected arrest: carry out CPR treatment if there is a reasonable possibility of success (if in doubt, start CPR and call for help).

YE S It is likely that the patient is going to die naturally because of an irreversible condition. Where a decision not to attempt CPR is made on these clear medical grounds, it is not appropriate to ask the patient’s wishes about CPR (or those close to the patient where the patient lacks capacity), but careful consideration should be given to whether to inform the patient of the decision. Consequences:  Document the fact that CPR treatment will not benefit the patient, e.g. ‘The clinical team is as certain as it can be that CPR treatment cannot Is there a benefit the patient in the event of a cardiac or respiratory arrest due to realistic advanced cancer, so DNACPR (Do Not Attempt CPR). chance that No  Continue to communicate progress to the patient (and to the CPR could be partner/family if the patient agrees or if the patient lacks capacity). This successful? explanation may include information as to why CPR treatment is not an option (as described above) and include; ‘Unfortunately CPR will not work in your circumstances and we need to ensure all others know about this decision to ensure your comfort at the end of your life, if that is OK?’  Continue to elicit the concerns of the patient, partner and family. Yes  Review regularly to check if circumstances have changed  To ensure a comfortable and natural death effective supportive care should be in place, with access if necessary to specialist palliative care, and with support for the family and partner.  If a second opinion is requested, this request should be respected, whenever possible. In the event of the expected death, AND (Allow natural Dying) with effective supportive or palliative care in place.

Y E S  In adults : is there an Advance Decision to Refuse Treatment (ADRT) refusing CPR, or a signed Welfare Does the Attorney order (with its accompanying 3 rd party patient lack Yes certificate) with the authority to decide on serious capacity? medical conditions- the most recent order takes precedence. Otherwise make a decision in the patient’s best interests, following the processes stipulated by law, e.g. the N Mental Capacity Act o Are the potential  When there is only a very small chance of success and risks and burdens of CPR there are questions whether the burdens outweigh the considered benefits of attempting CPR : the involvement of the patient Yes greater than the (or, if the patient lacks capacity, an ADRT, Lasting Power of likely benefits of Attorney as above or those contributing to Best Interests) in CPR? making the decision is crucial. When patients have mental capacity their own view should be the primary guide to decision-making. In cases of doubt or disagreement, a second opinion should be requested. N o CPR should be attempted

www.emas.nhs.uk

Monica  You visit Monica weekly and you now see a deterioration each week.  In bed most of time now, sleeping more  Eating less

A Few Weeks ACP inc. ADRT, PPC,DNACPR reviewed Fast track to Continuing Care completed if additional service funding required Prognosis Anticipatory medications supplied “a few weeks” Carer needs reviewed Support arranged for provision of terminal care in setting of patient’s choice e.g. Hospice at Home

Core 4