CARE TOWARDS END OF LIFE

Dr. Nadeesha de FonsekaConsultant AnaesthetistBH- Panadura

End of Life care

Do any of your patients ever die?

Then you need to think about end of life care.

END OF LIFE Likely to die within few hours, days

or within the next 12 months.

AIM

1. Create awareness about this group of patients

2. How, and what type of care is needed

3. How to Support the patients as well as the relatives

4. Ethical and legal issues

MRS. A – 60 YRS

Diagnosed pt with bladder CA with multiple bone secondaries. Presented with fever, cough and acute SOB and low BP.

Mr B – 80 YRS

Diagnosed pt with Hypertension and CRF. Needs support in feeding ,mobilising and other basic needs. Presented with reduced UOP, confusion and a Pressure sore on the Left hip.

MRS. C – 70 yrs

Diagnosed patient with DM and LVF with frequent exacerbations. Independant with regard to feeding, mobilising inside house, and dressing up.Having lot of family support . Presented with acute severe SOB and chest pain.

Mr. D – 30 YRS

Fit and well man, met with a RTA. Patient is in the ICU Day 10, on ventilatory support, diagnosed to be in a persistent vegetative state.

GROUP OF PATIENTS

• Advanced, Progressive, incurable diseases

• General frailty and co-existing conditions• Sudden catastrophic events• Persistent vegetative state (PSV)• Extremely premature infants

Equalities and Human rights

• The same quality of care as other patients

• Treat with dignity, respect and compassion

• Respect privacy and right to confidentiality

DECISIONS ON CARE ARE DIFFICULT

• Clinically complex (Multiple acute and chronic conditions)• Emotionally distressing (Doctor

Patient, Relatives, Medical Team)• Some may involve ethical dilemmas• Uncertainties about legal issues

Resource constraints

• Lack of availability of ICU beds

• Balance the duties towards the wider population

• Provide the best service within the resources available.

• Prioritise patients based on clinical need and capacity to benefit.

MOST CHALLENGING DECISIONS

• Withdrawal of treatment (Not Care)• Not starting a treatment if it prolongs life

Ex. AntibioticsCPRDialysisMechanical ventilationClinically assisted nutrition

(availability of resources)

BEST FRAME WORK

• Doctor and Patient making the decision together.• Capacity to decide at the time

of presentation?

Adult With Capacity to Decide

• The Doctor and Patient make an assessment of the condition and make decision.Doctor

- Specialist knowledge - Experience- Clinical judgement- Potential benefits and Risks of each option.- Patient should not be pressurized to accept.- Patient has right to refuse an option.

Adult With Capacity to Decide

• PATIENT • Decision making capacity should be

maximised. • Able to understand, retain and make the

decision weighing the information given and to express the decision.

Adult Lacking Capacity to Decide

• .Doctor makes the decision based on whether the treatment option will be of over-all benefit to the Patient– Advanced directives–Proxy–Previous wishes of patient.

COMMUNICATION WITH RELATIVES

– Doctor should respect their views and feeling as well.– Terminology and wording should

be used carefully,– Poor communication leads to legal

issues.–2nd opinion if serious difference of

opinion

PALLIATIVE CARE

• ObjectiveSupport the Patient to live as well as possible until they die

• Hydration • Nutrition• Management of distressing symptoms– Pain– Breathlessness– Agitation / Depression etc.

CPR / DNAR

Benefits of Prolonging Life Risks and burdens of Rx

CPR / DNAR (Contd.)

• Not only a clinical decision• Quality of life• Family support• Patient’s wishesIf resuscitated – Is multi organ support in an ICU appropriate ?

COMPLICATIONS OF CPR• Interventions are invasive

– Forceful chest compressions - fractures– Electric shock–Injecting Drugs– Ventilation + Intubation

• Hypoxic brain damage• Survive with disability• If unsuccessful patient dies in a traumatic

undignified manner.

What does a good death look like?

• Calm, controlled, pain free, at peace with self and important others

• Sudden but timely

Allow Natural Death

• This will ensure last hours or days are spent in their preferred place of care with the preferred people.

• Patient dies in a peaceful and dignified manner.

Thank you.

How people die remains in the memory of who live on.