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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 • • • • • • • • • 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 • • • • • 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 • • • • • • 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 • • • • • 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 • • • • • • 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 • • • • • 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 • • • • 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