Download Head and neck study day…… - Royal Surrey – County Hospital

Advance Care Planning
HEAD AND NECK STUDY DAY…..A MULTIDISCIPLINARY APPROACH
Defining End of Life
People are “approaching the end of life” when they are
likely to die within the next 12 months. This includes
people whose death is imminent (expected within a few
hours or days) and those with:
 Advanced, progressive, incurable conditions
 General frailty and co-existing conditions that mean they
are expected to die within 12 months
 Existing conditions if they are at risk of dying from a
sudden acute crisis in their condition
 Life-threatening acute conditions caused by sudden
catastrophic events.
General Medical Council (2010)
Publications
 In 2008 the DOH published The End of Life Care
Strategy – the strategy aimed to improve the end of
life care for all patients irrespective of diagnosis.
 In 2014 the End of Life Care Strategy’s fourth annual
reports’ focus was on supporting people to be cared
for and to die in their place of choice, providing the
community services to enable this to happen.
Enablers to improving end of life care
The National End of Life Care Programme (2012)
published a guidance pack identifying five key enablers to
assist healthcare providers in delivering high quality end of
life care:
 Advance Care Planning
 Electronic Palliative Care Coordination Systems
(EPaCCS)
 The AMBER care bundle
 The rapid discharge home to die pathway
 The Liverpool Care Pathway
Defining Advance Care Planning
 Advance care planning (ACP) is a voluntary process of
discussion about future care between an individual and
their care providers, irrespective of discipline. If the
individual wishes, their family and friends may be included.
It is recommended that with the individual’s agreement this
discussion is documented, regularly reviewed, and
communicated to key persons involved in their care
www.endoflifecareforadults.nhs.uk
Advance Care planning
 It is based on a person’s priorities, beliefs and values
and involves taking time to learn about end-of-life
care options and services before a health crisis
occurs.
 When one cannot express one’s own wishes,
professional care providers (e.g. treating physician,
other health care professionals) and/or other people
(e.g. family members, spouse) are forced to take
decisions during such as a crisis that may differ from
the patient’s wishes.
Advance Care Planning
Can cover anything to do with future care including:
 Thoughts on different treatments or types of care
 Religious or spiritual beliefs that wish to be reflected
in care
 Name of a person to be consulted in the future
 Appointing someone to make decisions when a
patient is no longer able to make decisions for
themselves
 Preferred place of care/death
When to Initiate a ACP Discussion
Usually takes place in anticipation of a future
deterioration with loss of capacity whereby the patient
is unable to make decisions and/or communicate their
wishes
 Life changing event
 Following a new diagnosis of life limiting condition
 Significant shift in treatment focus
 Multiple hospital admissions
Opportunities
 In oncology, many patients have a long disease
trajectory, during which events can occur that may
provide the opportunity to establish preferences.
 In palliative care, many of these topics become more
important and end-of-life issues should be discussed
with the patient, to know what the patient wants in a
specific situation.
Who Initiates the Discussion
Initiation of ACP discussion by a care provider requires
careful consideration:
 Appropriate communication skills
 Full knowledge of the person’s medical condition,
treatment options and social situation
 There may be someone more appropriate to carry out
this discussion e.g. specialist nurse
 The time and setting should be appropriate for a private
discussion
 May require several discussions for clarification and
comprehension of relevant information.
Advance Care Planning
 The discussion of advance care planning depends on
many factors, such as cultural background, religion,
legal framework, educational level, personality type,
age, personal life-and-death experiences and disease
status.
Where would you
most like to be
cared for?
Advance Decision to
Refuse Treatment
(ADRT)
Do you have any
comments or
wishes that you
would like to share
with others?
Preferences
regarding
future care?
DNACPR
Lasting
Power of
Attorney
Who else would you
like to be involved if
it ever becomes
difficult to make
decisions?
Organ
donation
Is there
anything you
would ideally
like to avoid
happening to
you?
Have you
made a will?
Benefits of Advance Care Planning
 Can provide the comfort of having a greater sense of control
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over what may happen in the future
Promotes discussion around understanding of illness and
prognosis
Can promote important discussions between family members
Provides valuable information about patient’s priorities which
can be considered in the future when acting in the patient’s
best interests
Identifies issues providing MDT with valuable information
which may need to be considered when planning treatment
Can provide opportunity to discuss appointing LPA or ADRT.
Challenges to Advance Care Planning
 Voluntary process and patient may not want to confront
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future issues.
Who is the most appropriate person to initiate the
discussion?
Need to have appropriate communication skills
Need knowledge of support, services and choices
available in particular circumstances
Need adequate knowledge of the benefits, harms and
risks associated with treatments or refusal of treatments
to allow patient to make informed choice
People change their minds.
Head and Neck Patient Considerations
 Do Not Attempt Cardiopulmonary Resuscitation
(DNACPR)
 Artificial hydration and nutrition
 Implications of cancer treatments
 Risk of bleed
Mrs Tracey- the Verdict
 Doctors will need to justify DNACPR decisions
 Keep an account of the discussions they have with the
patients and families involved
 If a patient has capacity there should be a presumption
that they should be involved in the DNACPR decision
 There must be 'convincing' reasons not to involve the
patient
 A clinician's belief that cardio-pulmonary resuscitation
will fail is not enough. Neither is the fact that the
patient may find the topic distressing.
Decisions Relating to Cardiopulmonary Resuscitation
 The guidelines identify the key ethical and legal issues that should inform
all CPR decisions. Key points emphasized in the new guidance include:
 The value of making anticipatory decisions about CPR as an integral part of
good clinical practice
 The importance of involving people (or their representatives if they are
unable to make decisions for themselves) in the decision-making process
 That when CPR has no realistic chance of success it is important to make
decisions that are in the best interest of the patient, and not to delay a
decision because a person is not well enough to have it explained to them or
because their family or other representatives are not available
 The importance of careful documentation and effective communication of
decisions about CPR.
Implications of Cancer Treatments
 Altered airway
 Changes to sensation
 Speech
 Swallowing
 Oral changes- trismus, dry mouth
 Changes to appearance
 Survivorship
Hydration and Nutrition
 Support patients to consider when they may wish for
an intervention
 When they may wish for an intervention to be
discontinued
Bleeding Risk- Head and Neck Cancers
 Surgery
 Radiotherapy
 Post Operative Healing Problems
 Fungating Tumour
 Systemic Factors
Carotid Artery Rupture
 Royal United Hospital Bath 2013
Carotid Artery Rupture: Related to the Terminal
Care of the Head and Neck Cancer Patient: Policy,
Procedure & Guidelines
Use of Benzodiazipines
 The dose should be given as 5mgs IV stat dose or 5-
10mgs SC/ IM stat dose. (Smith, 1992; Pereira &
Phan, 2004)
 The dose may then be titrated until the patient is
fully sedated (Forbes, 1997)
Opioid Use During Massive Haemorrhage
Morphine is not recommended as a first line
medication in this event for the following reasons:
 Supporting literature and anecdotal accounts of
witnesses to this event, there are no reports of pain.
 Due to the strict protocols on the storing, drawing up
of, and administering of, controlled drugs, there may
be unavoidable delays when administering the
morphine.
 There are connotations with euthanasia and ethical
dilemmas raised by the administering of an opioid if
the patient is in no pain.
Use of opioid
Therefore, it is not recommended in this event
EXCEPT for the following reasons:
 Should the patient have a bleed that is not likely to
result in immediate death and complain of PAIN
and/or BREATHLESSNESS, then these would be the
only indications to give morphine
or
 Should the patient be on regular opioids, the dose
given should be equivalent to their usual four hourly
dose of opioid. In an opioid naïve patient, 2.5mg of
morphine could be given subcutaneously
Managing the risk
 The goal of management of the event must be to
minimise anxiety, ease suffering and ensure death
with dignity providing a calm, reassuring and caring
atmosphere.
Thank you for you time
……..any questions