Download Managing Patients with Respiratory Disease at the End of life

Managing Patients with
Respiratory Disease at the End of
Life
Dr Barbara Downes
Dec 2011
Why is this important?
• Better patient care
• Better use of resources
• National policy
NICE Quality Standards for
EOLC
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Identification of patients
Communication
Holistic assessment
Management/Support—pt, families, carers
Coordination of care
Urgent care
Specialist palliative care
Care in the last days
Care after death
Overarching principles
• Care aligned to needs and preferences
• Increased time in preferred place of care
• Reduction in hospital admissions leading to
death
• Reduction in deaths in inappropriate places
eg A&E, ambulance
Introducing JB
70yr old male, married, adult children
PH: angina, AF
2009 pulmonary fibrosis
SOBOE but managing social activities
Well informed, knows poor prognosis
positive outlook, mood good
2010
• Supported by GP, thoracic med, palliative care
(and their teams)
• Hospital admissions X 3
• AF, chest infection, severe dyspnoea
• Each episode followed by:
Not back to baseline
Reducing confidence
Anxiety/fear
Increasing stress for patient and his wife
2010 Hospice Admission-change
of focus
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Taken to his bed
SOB on least activity
Fearful
Sorting out his affairs
Discussed future care wishes, dignity and fear of
being a burden
• Lots of discussion, patient/wife
• Discharged home with care
• Different expectations, more realistic, more
accepting
Jan 2011, Hospital admission
• SOB, chest infection
• Transferred to hospice at his request, but
ultimately wished to go home
• Day by day deterioration
• Calm, relaxed, no longer ‘fighting’
• Morphine soln, no other drugs
• LCP 13/1/11, died 15/1/11
? Successful end of life care?
• Collaboration between hospital, GP and
palliative care
• Patient supported to plan ahead and express
his wishes
• Hospital care when needed but didn’t die in
hospital
• Family supported and helped into
bereavement
End of Life Care
Which patients are we talking about?
NW End of Life Care Model
EOLC-Which COPD patients?
• Surprise question
• General decline, increasing care needs
• COPD, at least 2 of the following:
Severe disease FEV1< 30%
Frequent admission
LTOT
SOB less than 100m
R heart failure
Anorexia, NIV, resistant bugs
Who decides that the patient fits
these criteria?
Consultant? GP? Nurse? Patient?
Advancing Disease
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GSF register
Holistic assessment
Plan care based upon needs
Communication: patient, family, MDT
Start Advanced Care Planning
Communication: Hospital /Primary care
Holistic Assessment
Increasing Decline
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Continue to review and plan care
DS 1500
Continuing Heath Care
Manage symptoms
Continue to communicate and explore care
wishes
• Start to prepare for care in the last days
Managing Dyspnoea
• Exclude reversible factors/ maximise COPD
management
• Explanations/communication
• Control of breathing techniques
• Adjustment/adaptations
• Morphine regular/prn
• Benzodiazepines
• Regular review of management
General management
• Other symptoms: poor appetite, bowels,
pain etc
• Practical matters: dressing, bathroom,
getting out, equipment
• Mood/depression/anxiety/fear/panic
• Contact information
• Self help, coping strategies
• Carers
Who is coordinating care at this
stage?
The Last Days of Life
• Should be anticipated
• No reversible factors
• Progressive decline, struggling with eating,
drinking, drugs; bedfast; often asleep
• All agree—Dr, nurse, carers, (patient)
Medications
• Review and stop unnecessary drugs
• If using morphine for pain/SOB, continue as an
infusion (half the oral dose)
• prn morphine sc (1/6th the infusion dose)
• Midazolam 2.5-5mg prn (if needed 10-20mg sc
infusion)
• Hyoscine hydrobromide 400mcp prn sc
• Antiemetic; levomepromazine 6.25mg prn sc
Other tasks
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Explain to carers, deal with their issues
Make decision about use of oxygen
Communicate with DNs
Inform OOH services
DNAR
Plan for death out of hours
Prescribing
• Assess the patients symptoms, prescribe
appropriately
• Review current medications ?Already taking
opiates or benzodiazepines?
• Prescribe injectables enough for syringe driver and
prn
• Write up drugs on administration sheet/wardex—
this is a requirement for nurse administration
• Complete prescription correctly to avoid delays
Review the patient
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Medications may need adjusting
Support family and carers
Professional support
Every 3 days for LCP
Think about MCCD for deaths at weekend
Care after death
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Verification of death
MCCD
Inform other professionals
Bereavement support
The Primary Care Perspective?
• Questions
• Comments
• Issues
Summary
• End of Life Care starts 6-12 months before
death
• Identification of EOL patients should not
deny them care but ensure appropriate care,
• EOLC patients are ‘high maintenance’ if we
are to care for them properly