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Est. 2002

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Bradford VTS Online Resources:

Clinical Knowledge

Palliative & End of Life Care

DOWNLOADS

path: PALLIATIVE & END OF LIFE CARE

 

WEBLINKS

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 you have files you would like me to host on here and share with others, OR if you would like to help develop these pages further, then please email me.  
rameshmehay@googlemail.co.uk

Prescribing Tips

  • 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):
          1. Surprise question applicable ‘Would you be surprised if this patient were to die in the next few months, weeks, days?’
          2. NYHA stage 3/4 with ongoing symptoms despite optimal therapy
          3. Repeated admission with HF – 3 admissions in 6/12 or 1 admission aged >75 (50% 1 year mortality)
          4. Difficult ongoing physical or psychological symptoms despite optimal tolerated therapy
          5. Additional features: hyponatraemia, high BP, declining renal function, anaemia
  • 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

https://www.resus.org.uk/respect

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 – rameshmehay@googlemail.com

Some Scenarios

  • 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.  

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource. And of course, if you have developed a resource of your own, please email it to me to share with others.

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