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Palliative care

Palliative care. Jo Swallow and Mary Valentine GP Educators. F2 teaching session Sept 2012. Objectives. Understand the role of every clinician in End of Life care Introduction to symptom management at the end of life. Awareness of the Gold standards Framework for the dying patient

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Palliative care

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  1. Palliative care Jo Swallow and Mary Valentine GP Educators. F2 teaching session Sept 2012.

  2. Objectives • Understand the role of every clinician in End of Life care • Introduction to symptom management at the end of life. • Awareness of the Gold standards Framework for the dying patient • Appreciate impact of DNAR • Practice Communication skills in end of life care

  3. Mortality rate • What percentage of the population die every year? • A) 1% • B) 5% • C) 0.1%

  4. It affects us all • End of Life Care is important. • • 1% population die/year- mainly elderly non-cancer patients. • • Too few people die at home or their place of choice. • • Hospital admissions and deaths are expensive and may bepreventable - care must be brought closer to home. • • Everyone is involved in end of life care - most care is fromthe GP.

  5. Hearing the Bad News… • The Long Walk Home….

  6. Hearing the Bad News… • Your experiences • Think of a time when you have been involved: yourself, your family or friends…. Or caring for someone personally or professionally…. • Write the story….

  7. Hearing the Bad News… • Common themes?

  8. Hearing the Bad News… • Tips/Frameworks which you’ve come across/use.

  9. Breaking bad news frameworks? SPIKES • SETTING • PERCEPTION • INVITATION • KNOWLEDGE • EMPATHY • STRATEGY AND SUMMARY

  10. Breaking bad news frameworks… ABCDE • Advance Preparation • Build a therapeutic envionment/relationship • Communicate well • Deal with the patient and family reactions • Encourage and validate emotions

  11. Someone that did it well… Mr J L B Maketoni….

  12. How do GP’s fit in? • Identification: we’re often the first person to suspect the severity of the illness • Informing and explaining: we are often the one who has to tell them or explain/translate or reinforce what “the hospital says” • Continuity and coordination: we are the patient’s advocate and involved at all stages with the patient and their family.

  13. How do GP’s fit in? • The Gold Standards Framework is all about putting systems in place, taking a systematic approach to care. • There are seven C's, (key tasks)

  14. Communication • Coordination • Control of symptoms • Continuity and cross boundary working • Continued learning • Carer support • Care in dying phase

  15. How do you identify someone who is going to die in the community?

  16. Would I be surprised if this patient died in the next year? • The sensitivity of the surprise question "No" response was 75% and the specificity was 90%. Conclusions: • The surprise question is a simple, feasible, and effective tool to identify patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning.

  17. Advanced planning: DNR.. How do you feel about this being broached?

  18. Advanced planning • Do Not Resuscitate (DNR) forms vsAllow Natural Death (AND) forms, • Many hospices have a policy that they do not carry out CPR and patients have to "opt in" rather than "opt out" of resuscitation • Ultimately it is the doctor's decision whether or not it is in the patient's best interests for a resuscitation attempt to be made - doctors do not have to provide anything they perceive to be a futile treatment.

  19. Advanced planning • If relatives are offered "resuscitation" many will opt for this. However, if the success statistics, relative distress, morbidity and inpatient stays associated with CPR are discussed, many patients will not wish to undergo this intervention • paramedics will attempt CPR on a patient who undergoes cardiopulmonary arrest in an ambulance • Information to be recorded clearly in the notes

  20. Control of symptoms • Quiz in pairs/groups of 3.

  21. Control of symptoms-15 tripwires • Pain • Nausea and vomiting • Intestinal obstruction • Breathlessness • Cough • Haemoptysis • Respiratory tract secretions • Spinal cord compression • Superior vena cava obstruction • Hypercalcaemia • Management of the last few days of life • Terminal restlessness and agitation • Use of steroids • Miscellaneous problems • Indications for the use of a syringe driver in palliative care

  22. Helping the patient with pain • 15 min exercise • www.helpthehospices.org.uk/clip/pdf/hpp-1.pdf

  23. Consultation practice, in 3’s pt, dr and observer. • A worried wife.

  24. Feedback, Talking to patients about terminal illness • What are the barriers? • How do patients feel? • How do we feel?

  25. Bereavement Stages of bereavement: Denial Anger Bargaining Depression Acceptance Elisabeth Kubler-Ross.

  26. Understanding responses…. • It is quite normal not to ‘feel’ anything following a death; people often have a delayed reaction. • Some people don’t deal with their emotions for days, months or even years after the death. • Many people feel angry about death they can feel guilty about being angry – it is normal to feel a sense of injustice.

  27. Revisiting Objectives • Understand the role of every clinician in End of Life care • Introduction to symptom management at the end of life. • Awareness of the Gold standards Framework for the dying patient • Appreciate impact of DNAR • Practice Communication skills in end of life care

  28. Questions?

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