Bradford VTS Online Resources:
- 10 ways to help the bereaved and mourning.pdf
- 2ww referral – patient leaflet 2020.pdf
- a model of good practice for palliative care.doc
- advance care plan – top tips.pdf
- advance care planning.pptx
- advanced care plans – emergency care plans – lasting power of attorney – RESPECT.pptx
- assessing spiritual needs.pdf
- bereavement guidance.pdf
- bereavement reaction assessment tool.docx
- bereavement risk assessment tool – BRAT.pdf
- cancer communication toolkit by NW London Cancer Network.pdf
- cases – death dying and the coroner.doc
- cases – pain management.ppt
- cases – terminal care.doc
- chf and palliation.pdf
- complementary therapies in cancer care.pdf
- creative health reading list.pdf
- death and dying conversations – and looking after ourselves.ppsx
- decision making at end of life.ppt
- DNACPR policy rotherham.pdf
- ds1500 form.doc
- dying with dignity.ppt
- e is for energy.pdf
- emergencies in cancer care – tutorial.doc
- emergency care plans – discussing – infographic.pdf
- home visits to dying patients – fab prompts and tlc.docx
- improving cancer care.ppt
- improving diagnosis of cancer – a toolkit for gp.pdf
- on talking with cancer patients by Dr McAdam.pdf
- opioid conversion chart 2021.pptx
- oral cancer aide memoire.pdf
- pain control – fentanyl patches – guidelines for use.pdf
- pain control – opioid conversion diagram – leeds 2016.pdf
- pain control – opioid conversion diagram – the best.doc
- pain control – opioid conversion table.pdf
- pain control.pdf
- palliative care – from worcester vts.ppt
- palliative care – not just opiates.ppt
- palliative care – top ten tips.pdf
- palliative care end of life top tips 2020.pdf
- palliative care handbook by rowans hospice 2019.pdf
- palliative care handbook by wessex 2019 – exceptional.pdf
- palliative medicine core curriculum.doc
- palliative medicine with an elderly focus.pdf
- pbl on death and dying.doc
- pepsi-cola holistic reviews.doc
- practicalities of palliative care.ppt
- primary palliative care – a model of good practice.doc
- prognostic indicators.pdf
- quality improvement toolkit for early diagnosis of cancer.pdf
- ReSPECT – communication tips.docx
- ReSPECT – core competencies.docx
- ReSPECT – emergency care treatment form – what it is and what it is not.docx
- ReSPECT Conversations in COVID.pdf
- symptom control – confusional states in advanced cancer.pdf
- symptom control – dyspnoea.pdf
- symptom control – nausea and vomiting in palliative care.ppt
- symptom control – nausea and vomiting.pdf
- symptom control – nausea and vomiting.ppt
- symptom control – quick guide rotherham.pdf
- ten top tips for palliative care patients.pdf
- terminal care – agitation.pdf
- terminal care – anticipatories.ppt
- terminal care – anticipatory drug prescribing.pdf
- terminal care – anticipatory medication.doc
- terminal care – breathlessness.pdf
- terminal care – end stage disease indicators.pdf
- terminal care – estimating length of life in palliative patients.pdf
- terminal care – nausea & vomiting.pdf
- terminal care – pain control.pdf
- terminal care – secretions.pdf
- terminal care – symptom control in the last 48 hours (1).pdf
- terminal care – symptom control in the last 48 hours (2).pdf
- terminal care – symptom control last days.pdf
- when someone dies – practical aspects.doc
- Cancer Maps – Ben Noble’s
- Cancer Maps – YouTube Tutorial
- Q-Cancer score
- RATS – symptom probability of cancer
- End of Life super-condensed curriculum – what you should know (RCGP)
- WMPCP Symptom Control in Palliative Care website (Amazing!)
- Bradford & Airedale Palliative Care Guidance (Excellent too)
- Yorkshire & the Humber – Symptom Management in Palliative Care 2019
- WMPCP Symptom Control in Palliative Care as a pdf
- CLiP (Newcastle) – these 15 min worksheets are brilliant!
- CRUK – gp trainer hub – tools for teaching your trainee
- CRUK – diagnostic tools for use in cancer
- CRUK – causes of cancer and ways to reduce risk
- CRUK – cancer treatment and other post-diagnosis issues
- CRUK – cancer statistics
- CRUK – cancer screening
- CRUK – learning, support and resources for health professionals
- OSCEs in Palliative & Cancer Care (BVTS)
- BMJ audio – Emergency Care Plans
- ReSPECT form
- The Other Side – a true story of one doctor’s journey as a patient coming to terms with a terminal cancer diagnosis
OTHER USEFUL BITS & BOBS
- The Yorkshire Symptom Management booklet is now available as an app on Apple and Android
- The Palliative Care Guidelines website – has a helpful section on syringe driver compatibility
- Dr Kathryn Mannix, a retired palliative care consultant, has produced a short video explaining the dying process in non-medical language: YouTube-Mannix
IMPORTANT BVTS WEBPAGES
- If a patient’s pain is not controlled, increase the 24h opioid dose by 1/3rd. So, if they are on MST 30mg bd, increase to 40mg bd.
- If you are increasing the regular pain relief dose, then remember to increase the breakthrough dose too.
- The breakthrough dose of opiates is 1/6th of the total daily dose of opiates.
(MST 15mg bd = breakthrough dose 5mg oramorph. MST 30mg bd = breakthrough dose = 10mg oramorph). Please double check with senior if unsure.
Remember to calculate this and include patches as well as oral medications and syringe drivers. Ask palliative care for advice if needed.
- When starting a syringe driver don’t remove an existing opiate patch but continue to change it when scheduled.
If their background opiate analgesia needs to be increased add it into the syringe driver and update the PRN dose calculation.
- Remember not all pain is opioid responsive.
It can be helpful to ask the patient whether previous background dose increases made a difference or whether PRN opioid doses help- if the answer is no, consider adding an adjuvant rather than continuing to increase opiates. For example, bone pain from bone mets – usually responds better to NSAIDs than opioids.
- Know the features of opioid toxicity (confusions, picking at things in mid air, hallucinating). Most likely if opioid doses increased too much too suddenly.
- Always double check or even triple check your calculations. Ask a colleague to double check if you want to be even more safe.
- Levomepromazine is an excellent anti-emetic in palliative care which covers a wide range of receptors and has a long half-life.
The oral and sub-cutaneous dose for nausea is 2.5-6.25mg.. The 25mg tablets cut into quarters are considerably cheaper than the 6mg tablets but you may need to switch to these if the 6.25mg dose is too sedating.
- There are loads of good guides on palliative care symptom control drugs (e.g. nausea, vomiting, constipation, pain and so on). See resources above.
Prescribing in Heart Failure
- How to recognise patient with HF approaching end of life
- GSF Prognostic Indicator Guidance (at least 2 of):
- Surprise question applicable ‘Would you be surprised if this patient were to die in the next few months, weeks, days?’
- NYHA stage 3/4 with ongoing symptoms despite optimal therapy
- Repeated admission with HF – 3 admissions in 6/12 or 1 admission aged >75 (50% 1 year mortality)
- Difficult ongoing physical or psychological symptoms despite optimal tolerated therapy
- Additional features: hyponatraemia, high BP, declining renal function, anaemia
- GSF Prognostic Indicator Guidance (at least 2 of):
- Disease-modifying therapies at maximally tolerated doses also help to alleviate symptoms. This includes ACE inhibitors, beta-blockers and aldosterone antagonists.
- Opioids can be useful for managing breathlessness in heart failure.
- Low dose oral morphine is the usual first line opioid (e.g. morphine MR 5mg BD or 2.5-5mg morphine PRN).
- If there is significant renal impairment (eGFR <50) then consider low dose PRN morphine or oxycodone first line instead – discuss with specialist palliative care if unsure.
- Evidence suggests that when used for breathlessness, opioid doses in excess of morphine 30mg (or equivalent) are associated with increased mortality, so total daily doses should remain below this.
When would you refer to Palliative Care Services?
The patient has an active, progressive and usually advanced disease for which the prognosis is limited (although it can be several years) and the focus of care is quality of life. They should be on the GDF register. And the patient has hopefully consented to you referring to Palliative Care services.
You may want to refer on the grounds of one of the following unmet needs:
- uncontrolled or complicated symptoms.
- Specialised nursing – referral for IV therapies
- Complex psychological/emotional issues.
- Complex social issues.
- Difficult decision making about future care.
The Last Days of Life - practicalities
- Where ever you are, there will be 24/7 Palliative Care Consultant support if you need advice about palliative care issues.
- When you prescribe anticipatory medication, particularly for patients in care homes, task the District Nursing team. They will also make contact to support good end of life care, not just administer medications.
- Your medical computer system (EMIS, SystmOne etc) – will have sections to make prescribing easier . For example, there will be drop-down boxes with medication names and doses on the Anticipatory Medication and Syringe Driver charts. Ardens also has a brilliant section on Palliative Care to make your life easier.
ReSPECT has replaced DNACPR
What is it
- Recommended Summary Plan for Emergency Care & Treatment
- A personalised future emergency plan. One section of the Advanced Care Plan umbrella – specifically focusing on “in the event of an emergency”.
Why ReSPECT? What was wrong with DNACPR?
- DNACPR – often negative for patients (because they are not involved), and negative for docs (who don’t like doing it/making decisions on patients without involving them)
- So, ReSPECT encourages us, health professionals, to INVOLVE the patient – it is there life after all. And to involve them EARLY rather than late on when they might not be in a state to make decisions.
In practice, how does it translate?
- We should be presumptive in favour of patient involvement legally – i.e. just involve them in the decision making.
- Leaving someone “for CPR” when they may not want it is no less a breach of their human rights
- Where no explicit decision – there should be an initial presumption in favour of CPR
- But this DOES NOT mean the indiscriminate application of CPR that will be of no benefit and not in a person’s best interests.
Top tips in applying it
- Cover what treatment wanted AND what treatment not wanted
- Do it early – esp those end of life, at risk of cardiac arrest.
- Don’t just think the elderly. It’s for everyone, at any age.
- Remember, this is about EMERGENCY CARE & TREATMENT
- Once you have filled in the form…
- when to review?
- who keeps it?
- summarise the document verbally to the patient – i.e. what you have agreed, check understanding, make adjustments if needs be.
If in doubt, seek the opinion of your medical protection organisation and your local adult/child safeguarding team.
- If you would like to have a go at adding some “top tips” to this page for this specialty (and have your name displayed proudly with bradfordvts), please email me – email@example.com
- What if patient wants resus and as a clinician you feel it is futile
- Re-open the discussion – you need a deeper conversation.
- If you really think it is futile, and the patient still wants it, that usually means you have not explained the pros and cons well enough.
- Go back and do more discussion. This is not about you over-riding their decision, but both of you aligning your viewpoints and shared-decision making.
- What if patient’s advocate wants it, and as a clinician you feel not in patient’s best interests
- Like above, re-open the discussion – you need a deeper conversation.
- If you really think it is futile, and the advocate or relative still wants it, that usually means you have not explained the pros and cons well enough.
- Go back and do more discussion.
- If you feel as a clinician you have done your best to get a conversation going and good explanations – and that it would be futile – but the relatives still wants it – then you may need to get a court order. Talk to your medical protection organisation first. It is VERY RARE to have to go down this route.
- Does the patient’s/patient’s advocate decision override the doctors when they are at variance?
- No, it doesn’t. If you think it is futile and not in the patient’s best interests, then that is an important medical decision.
- HOWEVER, I cannot emphasise enough how you need to go back to having a discussion.
- You should not be autocratic or dictatorial when there is a variance of opinions. The variance signals the need for more discussion.
- Deeper and more meaningful discussions usually will help all parties get to the “right” decision.