OBJECTIVES FOR TODAY

Transcription

1 LCP STUDY DAY

2 OBJECTIVES FOR TODAY WHAT IS THE LCP AND HOW DO WE USE IT (Community and Hospital) LOOK AT VERSION 12 COMMUNICATION SKILLS IN END OF LIFE SPIRITUAL CARE HOSPICE CARE SYMPTOM CONTROL IN END OF LIFE PATIENT AND FAMILY EXPERIENCE MARIE CURIE DISCHARGE LIAISON NURSE ROLE OF THE PATIENTS AFFAIRS OFFICER AFTER DEATH CARE

3 How we care for the dying must surely be an indicator of how we care for all of our sick and vulnerable patients. Care of the dying is urgent care; with only one opportunity to get it right to create a potential lasting memory for relatives and carers Professor Mike Richards ( 2007)

4 How it works Document that brings together all the essential elements of dying Provides clear guidelines for evidence-based practice Focuses on comfort and symptom management Nutrition and fluids and treatments reviewed. Holistic approach, psychological and spiritual. Organises the process and encourages review.

5 Why it works Fosters communication between patient, carers and multi-professional team Provides focus to support care givers decision making empowers care givers with confidence Supports junior staff. Promotes education. Ensures that specialist expertise is sought appropriately for complex needs

6 COMPLEXITIES OF COMMENCING THE PATHWAY

7 Common signs and symptoms of the final stage of dying How do we know if the patient is dying?

8 Principles to remember when considering whether a patients death is imminent Has there been a significant deterioration in their condition over the last few years/months Assess by talking to patient, their family and reviewing their medical notes A deterioration may indicate that they are heading towards the end of life But some patients may deteriorate rapidly without this Is there a day to day deterioration in the patients condition? If there is a day to day deterioration, having considered everything above, the patient may well be dying

9 Common signs and symptoms of the final stage of dying Profound weakness Bedbound Needs assistance with all care Loss of interest/diminished intake of food and fluids Difficultly swallowing medicine Drowsy or reduced cognition May be disorientated to time and place Difficulty concentrating

10 Signs and symptoms of the final stage of dying Gaunt appearance Peripherally shut down Cool and cyanosed extremities Low BP Variable pulse Decreased urine output Changes in breathing pattern Noisy breathing death rattle Cheyne-stokes respirations In summary when there is a day to day deterioration particularly to strength, appetite and awareness.

11 Principles to remember when considering whether a patients death is imminent Ensure that all reversible causes of deterioration have been considered Appropriate assessment Appropriate treatment Symptoms controlled Rehabilitation optimised Remember the complete picture Appropriate assessment and treatment will be different for different patients Do not just write off elderly patients, but intensive investigations or treatment may not be appropriate The reversible causes should be considered, not necessarily treated, as this will not always be appropriate or possible

12 Identifying appropriate patients for the LCP Patients whose death is hours or days away Diagnosed as dying (Version 11) The patient is likely to be Bed bound Semi-comatose Only able to take sips of fluid No longer able to take tablets Multi-disciplinary decision (version 12)

13 Barriers to diagnosing dying Barrier Hope that the patient may get better No definitive diagnosis Pursing unrealistic or futile interventions Disagreement about the patients condition Failure to recognise key signs and symptoms Poor ability to communicate with family and patient How addressed by LCP If patient improves, they can be removed from the LCP LCP helps us to realise we will not always find a diagnosis Prompts discussion as to whether this is appropriate Prompts discussion and decision making LCP document and LCP teaching helps to provide this information Prompts communication at key moments, encourages staff to seek further communication training

14 Barriers to diagnosing dying Barrier Concerns about withdrawing and withholding treatment Fear of foreshortening life Concerns about appropriateness of resuscitation Lack of knowledge of how to prescribe appropriate drugs Cultural and spiritual barriers How addressed by LCP Provides opportunity to discuss whether this is appropriate Often due to lack of knowledge of whole situation Provides opportunity to discuss whether this is appropriate Information given on LCP Encourages discussion

15 Effects on patient and family if a diagnosis of dying is not made Patient and family are unaware that death is imminent Patient and family loses their trust in the doctors if the patients condition deteriorates without acknowledgement that this is happening Patient and relatives get conflicting messages from the multi-professional team Patient and family feel dissatisfied

16 Effects on patient and family if diagnosis of dying not made Cultural and spiritual needs not met At death, cardiopulmonary resuscitation may be inappropriately initiated Patient dies with uncontrolled symptoms, leading to a distressing and undignified death All of the above lead to complex bereavement problems and formal complaints about care Substantial effect on the patient and family LCP gives the support needed to ensure this does not happen

17 Exceptions that make diagnosing dying difficult Sudden death Will always be some patients that die suddenly without showing any of the common warning signs Patients with chronic illness Often have gradual deterioration over years/months with several episodes of acute illness, that they may die from Of course we do not know when they will die

18 Exceptions that make diagnosing dying difficult Patients with chronic illness So consider all the points mentioned and put the patient on the LCP if appropriate They can always come off the LCP if they improve

19 Conclusions Dying is difficult to diagnose There are common signs and symptoms of impending death, but there will always be exceptions to these Sometimes it is difficult to decide whether patients should go on the LCP or not After following this guidance, if in doubt put patient on the LCP, explaining concerns to patient and family Putting the patient on the LCP at the appropriate time can make a considerable difference to the patient and family

20 THE PROCESS AND PAPERWORK MDT decision that patient is dying. Print out paperwork and leaflets from pink book. Senior clinician will sign paperwork (Get endorsed by consultant/registrar at earliest convenience) Dr and Nurse to complete first assessment. All of this in communication with family/significant others, if appropriate. Look through the document.

21 Goals and variances. Check the goal If it has not been achieved, document the reason/rationale/intervention and outcome Remember..Review LCP if change in condition/concerns/every 3 days