Care of the Dying - in 45mins?

1. Care of the Dying - in 45mins? How not to send them to sleep

2. The task… • 50 third year students on second term clinical placement at acute trust • 0815hrs start • Predefined topics (curriculum)

3. Perception of death Quality of life Cure at all costs? Basics of palliative care Key players WHO definition & goals Palliative care services development Concept of ‘total pain’ Assessment for palliative care Physical, psychologic, social, spiritual Ethical issues in palliative care Euthanasia Resuscitation Withholding fluids Med school’s objectives

4. Some Learning Theory • Building blocks • Pre-requisite knowledge - need to re-activate it • Presenting new material • Eliciting a change in practice/performance

5. My lecture outline • A comparison of modern and ancient societies’ views on death • A case scenario - what is it like to die in an acute trust • Facts on where people die and what they die from • Kübler-Ross - 5 stages of dying • The Hospice Movement • Definitions of Palliative Medicine

6. My lecture outline (cont.) • Pain control and Palliative care assessments • Dealing with the request for euthanasia as a communication skill • The ethics and law surrounding euthanasia, and key definitions • Ethical decision making at the end of life • CPR • Summary

7. Grab their attention at the start • A provocatory question related to their med school interview

8. …that interview for medical school • Did you say… • “I want to care for patients” or that “I want to look after people”?

9. …that interview for medical school • Did you think… • “I want to care for dying patients” or that “I want to look after people who are dying”?

10. Modern and Ancient Societies’ views on Death & Dying • 2-way discussion • Their innate attitudes • Hard for both old society and still hard for contemporary society to discuss • All views welcome - facilitates exploration of attitudes

11. 2. The Case Scenario • Storyboard: a student clerking of an elderly patient with an acute stroke • recall of clerking skills • But what was it like for the patient: same storyboard from patient’s angle • Introduction of new stimulus material: clinical management, discussions with relatives re: CPR, accidental injury in hospital requiring intensive care • Death is the outcome • To follow-up patients they clerk. To appreciate what dying in a hospital might be like

12. What Miss Smith saw

13. What Miss Smith saw We could control her BP, her cholesterol, and then if CT scan excludes a haemorrhage we can start her on anticoagulation for her irregular pulse

14. What Miss Smith saw

15. What Miss Smith saw

16. What Miss Smith saw

17. What Miss Smith saw

18. 2 buzz groups (1min) Descending order of proportion on inpatients dying from cacner, circulatory problems, respiratory conditions & neurologic conditions Recall of basic epidemiology concepts and integration with mortality of common pathology 2nd buzz group Draw with non-dominant hand the scene they picture when they are on their deathbeds. Exploration of attitudes: The majority of patients do not wish to die in hospital 3. Where patients die and what they die from

19. 4. Kübler-Ross - 5 stages of dying • To revise the stages of dying and visualise how they apply to a patient with terminal illness • An MCQ (various orders of the stages as options) - coloured handout: self-assessment to aid recall of pre-requisite knowledge

20. Doctors caring for the dying – 1960s • Dame Cicely Saunders founded St. Christopher’s Hospice in London • Established that morphine given to cancer patients gave excellent control of pain with no risk of addiction whatsoever • Realised the importance of caring for the bereaved family and being aware of the psychosocial context of the patient

21. Doctors caring for the dying – 1960s • American Psychiatrist, Elisabeth Kübler-Ross • “On Death & Dying” (5 stages of dying) • Interviewed over 200pts who were terminally ill (handout shows how) July 8, 1926 - August 24, 2004

22. 1960s - Kübler-Ross: Stages of dying (on being told you have a terminal illness) 2nd STAGE ANGER Oh..yes, it is me Those bloody nurses, I never get any peace. There’s no privacy when you’re stuck in here

23. 1960s - Kübler-Ross: Stages of dying (on being told you have a terminal illness) 2nd STAGE ANGER Oh..yes, it is me She doesn’t realise how painful it is for them to see her dying and angry at the same time Where the hell’s my family when I need them?

24. 5. The hospice movement • To appreciate the multi-disciplinary tearm approach to managing patients who are ill

25. The hospice movement OUTPATIENT CLINICS e.g. for pain DOCTORS HOSPITAL SUPPORTTEAMS ALTERNATIVE MEDICINE THERAPISTS PSYCHOLOGISTS MACMILLAN NURSES IN-PATIENT CARE DAY CARE BEREAVEMENT SUPPORT PHARMACISTS MARIE CURIE NURSE HOME CARE or HOSPICE AT HOME PHYSIOs and OTs

26. To recall the GMC duties of a doctor and understand how they marry up with the philosophy of modern palliative medicine (WHO) 2-way discussion with flip-chart: recall GMC duties Presentation of stimulus material (philosophy) Discussion helps students learn (build) relevant attitudes on basis of principles they already know 6. Definitions of Palliative Medicine

27. What is modern Palliative care? • WHO definition – Palliative care… • Affirms life and regards death as a normal process • Neither hastens nor postpones death • Provides relief from pain and other distressing symptoms • Integrates four major areas of a patient’s care: the psychologic, the physical, the social and the spiritual • Offers a support system to help patients to live as actively as possible until death • Offers a support system to help family cope during the patient’s illness and in their own bereavement Respect the right of patients to be fully involved in decisions about their care Not allow your personal beliefs to prejudice your patients’ care Keep your professional knowledge up to date Work with colleagues in ways that best serve patients’ interests

28. A necessary response to modern medicine which has prolonged the “dying trajectory” for most diseases Oncologists work hard to improve survival outcomes for most malignancies GTN 1879 DIAMORPHINE 1898 METOCLOPRAMIDE 1944 ASPIRIN 1899 HEPARIN medical student J McLean 1916 STREPTOKINASE late 80s, early 90s BETA BLOCKERS 1994 EXTERNAL DEFIBRILLATORS from 90s ACE INHIBITORS 1993 ANGIOTENSIN II RECEPTOR ANTAGONISTS 2000 DIGOXIN over 200yrs old MAINSTREAM USE FROM 1996 SPIRONOLACTONE from 1996 What is modern Palliative care?

29. To provide students with a framework within which they can build their learning of palliative medicine Separation of domains of knowledge for clarity You will need to KNOW: About DISEASES, & their natural history About DRUGS, & their safe use You will need to be SKILLED: In communication To perform practical procedures You will need to have ATTITUDES: - That focus on empathic and holistic patient care 7. Pain control and Palliative Care Assessments

30. You will need to know the WHO analgesic ladder 3 Strong opioid + Non opioid 2 Weak opioid + Non opioid 1 Non opioid

31. Anna is a 45yo married mother of children aged 7 & 11. She was recently found to have spinal metastases from breast cancer. She comes to your pain clinic How knowledge is used in the management of a patient’s problem Brainstorm - key Qs or issues they wish to focus on Helps students to practically apply knowledge 7. Pain control and Palliative Care Assessments

32. Anna is a 45yo married mother of children aged 7 & 11. She was recently found to have spinal metastases from breast cancer. She comes to your pain clinic Can I recognize patterns of pain (visceral, bony, neuropathic, soft tissue, incident) What shall I check for on examination What are the best drug & non-drug strategies What will she have tried already How will I reassure her about starting morphine Who else can help me How can I give her hope and explain my management plan to the family Management of pain – “total pain”

33. 8.&9. Euthanasia - definitions, communication skills and the law • To recall the definition of euthanasia and its variants • Self-assessment MCQ - try to gain clarity between active, passive, voluntary, assisted suicide • To appreciate why patients ask for euthanasia • Recall of stages of dying (Brainstorm) to re-inforce attitude that terminally ill patients are fearful of dying - link this with euthanasia

34. 8.&9. Euthanasia - definitions, communication skills and the law • To provide a checklist for approaching communication with a patient who requests euthanasia • (No time to practise this skill)

35. Get ready Get the patient/relativeto talk first – ask open questions, use your silence What has made them come to ask you for euthanasia Try to understand the reason for the request. Is it a mark of distress or a calculated choice? Be empathic: sense what they might be feeling/thinking. Respond accordingly, watch for cues, respond with open questions Explain that you cannot perform euthanasia. Try to answer the distress behind the request Share information in easy to understand language. Don’t dominate Summarise the discussion. Let them know you will see them again after they’ve had more time to think about what you’ve said Let them know what to expect next

36. 8.&9. Euthanasia - definitions, communication skills and the law • To appreciate the on-going legal/moral debate on euthanasia • 2 way discussion: would you permit assisted suicide in this case (both are paralysed)? • Attitudes of others in the audience • Legal differences

37. Active assisted suicide • Paralysed by MND • Wanted a change in the law to allow her husband to end her life at a time of her choosing

38. Active assisted suicide = illegal • Paralysed by MND • Wanted a change in the law to allow her husband to end her life at a time of her choosing • Court decided “no, even though you are competent to make this choice” The Law has taken all my rights away

39. Passive assisted suicide • Paralysed by spinal haemorrhage, but kept alive on a ventilator • Wanted doctors to stop keeping her alive on a ventilator Ms. B v NHS trust

40. Passive assisted suicide = legal • Paralysed by spinal haemorrhage, but kept alive on a ventilator • Wanted doctors to stop keeping her alive on a ventilator • Court decided “you are competent, and have the right to refuse life-saving treatment. Therefore the doctors are acting unlawfully in keeping you alive” Ms. B v NHS trust

41. Current UK law is contradictory End result (assisted suicide) is the same – why should the means to achieve this matter to the courts?

42. 10. Ethical decision making at the end of life • To appreciate the 5 principles of medical ethics and to appreciate how they are applied when managing the terminally ill • Brainstorm: recall of principles • Link these principles to questions doctors ask • A case example (real patient management problem)

43. Principles of medical ethics as applied to the terminally ill • Will this active clinical measure (antibiotics, fluid) provide good quality of life? • Can I be sure that this active clinical measure will not prolong suffering of my patient? • Is this what the patient truly wants or what I want (“treating” my own conscience)? • Is this the best use of limited resources? • Am I acting within the law? Beneficence Non-maleficence Autonomy Justice Legality

44. Previously expressed views on such issues in the past? Any advance statement? Who will communicate this with the relatives? Is there another clinician or GP who knows her well and can inform us? Does the whole team agree? What do those close to the patient think that Mrs. Pierce’s views would be? Who is making the decisions? Mrs Pierce, MS for 25 years, admitted with pneumonia. Unable to communicate, cannot protect her airway. You think she may be dying. Antibiotics? Drip? NG feeding? CPR? Will any of these interventions reduce suffering in the dying process? Is she dying because of her primary illness MS or could it be something else? How will the benefits and adverse effects be assessed? What is my intent with the intervention? What distress might these active interventions cause? Is this acceptable? What maximum quality of life could we achieve for this lady? Is this acceptable? What is the likelihood that the intervention will be beneficial?

45. 11. CPR • To know the odds of survival post inpatient cardiac arrest treated with CPR and to briefly understand how DNR decisions are made • 2 way discussion (if your gran…). Asked what they think the odds of survival are. Discern true fact from attitude

46. 12. Summary and questions • Opportunity for questions (Clarification) • Enhance retention • Respect patients’ wishes where possible • Understand how individuals approach death and dying • Reminder of what knowledge and skills students will need

47. Constructivism - a theory of learning • Building blocks • Pre-requisite knowledge - need to re-activate it • Presenting new material • Eliciting a change in practice/performance • Techniques • Discussions, self-assessment, brainstorm, buzz grps (and many more)

48. Ask yourself: what is your conception of teaching? • Imparting information to my students • Structuring knowledge for my students • Facilitating a student-teacher interaction • Helping students to understand what I know • Encouraging the intellectual development of my students

49. William Osler (1849-1919): It’s more important to know what sort of person this disease has, than what sort of disease this person has.