Last Year of Life Road Map - Gold Standard Framework

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Palliative Care - Top Tips - GHFT

Please do this early, better to have them in the house weeks before needed than not at all and cost effective overall.

  • Use this Medication Prescription chart for anticipatory prescribing - remember standard anticipatory medications may need to be adapted if already on background pain relief/anti-sickness etc.

Please also see the following:

  • More research encouraging their use than benzodiazepines, even in non-malignant conditions
  • Any opioid – BuTrans patches can be helpful as doses are low
  • Avoid constipation – even more miserable when breathless
  • Antiemetics only as you start them, no permanent need once established on opiods
  • SOB at EOL - consider a syringe pump in the dying phase (morphine 10mg and midazolam 10mg if opioid naïve)
  • Guidance on intractable breathlessness available soon

It is still a medical decision – The Court of Appeal made it much more of a big deal that we discuss it with each patient unless very good reason not to i.e. demonstrable psychological distress and ensure this is documented…

WHEN MEDICALLY FUTILE:

Not

  • ‘would you like to be resuscitated?’

But:

  • ‘a resuscitation attempt when your heart has stopped because of cancer / heart failure / COPD highly unlikely to work and would not return you to how you are now, would only prolong the dying phase’

Patient should be informed of decision but not making the decision.

'What is in the clinic letter' may not be what the patient understands...

BUT

  • 'What is your understanding of all this?'
  • 'What are your expectations with this illness/about your health?'
  • 'When you look ahead, what sort of thing comes to mind?'

Capture that conversation. Complete a ReSPECT form and update the Summary Care Record to show the patient has a ReSPECT form.

  • Often helpful to focus on unacceptable outcomes but be specific: i.e. 'I do not wish to be artificially fed by intravenous or enteral (NG/PEG) means'
  • Avoid hospital admission if at all possible
  • IV antibiotics, tube feeding, resus
  • Write it down; a letter, the ACP green booklet, Out of Hours Computer Systems...
  • Share the decisions with acute sectors

  • Living with uncertainty is difficult but it is not depression
  • Or is it?
  • You are the best judge as you knew them before they were ill
  • Criticism for under-use of antidepressants in palliative patients
  • Key role we have is ‘walking alongside’ people through the uncertainties and decline.

Please review meds early into metastatic disease process or once signing DS1500

  • Anti-hypertensives e.g. Amlodipine, Doxazosin
  • Statins: NNT for benefit to patient when prognosis 6/12 is very, very high
  • Keep things that will help symptomatically e.g. anti-anginals, diuretics, Digoxin
  • 3 years Alendronic Acid now felt to have given lifetime benefit anyway

Always call Palliative care if you aren't sure! Please see the Services and Referrals section for full contact details.
Special Patient Information - SWASFT

SWASFT ambulance crews now have access to the patients Summary Care Record via their handheld devices. Unfortunately, the hub where 999 calls are taken do not yet have the same access. For now it is important to update both the SCR AND to inform SWASFT by email; swasnt.clinical-alerts@nhs.net so that calls can be managed appropriately.

As of 1 February 2017, South Western Ambulance Service (999) will no longer be able to receive special messages, DNACPR advice or other patient information via Fax. This is because faxing is considered insecure and creates a clinical risk. This means that any of your patient care plans/DNACPR decisions currently being faxed, will now need to be supplied electronically.

Please follow the resource link below to the SWAST website to access the Special patient Information form (this is referred to as 'Clinical alert in the End of Life Shared Care Plan).

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