Palliative and End of Life Care

Flashcards created from the lecture notes on Palliative and End of Life Care, covering core definitions, national statistics, identification tools (GSF PIG), advance care planning, mental capacity, last days of life care, and physiotherapy symptom management.

How does the World Health Organization (WHO 2002) define palliative care?

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

According to the National Palliative and End of Life Care Partnership (2015), when are patients considered to be 'approaching the end of life'?

When they are likely to die within the next 12 months. This includes patients whose death is imminent (expected within a few hours or days) and those with: a) Advanced, progressive, incurable conditions; b) General frailty and co-existing conditions expected to die within 12 months; c) Existing conditions at risk of dying from a sudden acute crisis; d) Life-threatening acute conditions caused by sudden catastrophic events.

What is the primary difference in timeframe between End of Life Care (EoLC) and Last Days of Life Care (LDoL)?

End of Life Care (EoLC) applies to patients in up to the last 12 months of life, whereas Last Days of Life Care (LDoL) refers to care delivered in the last few days or weeks of life.

According to the Office for National Statistics, what was the leading cause of death overall in England and Wales in 2022?

Alzheimer's and Dementia, accounting for 11.4% of all deaths.

What were the leading causes of death specifically for men and women in England and Wales in 2022?

For men, the leading cause of death was Ischaemic heart diseases (IHD), accounting for 13.3% of male deaths. For women, it was Alzheimer's disease and dementia, accounting for 15% of female deaths.

What percentage of the UK population dies each year, and what proportion of these deaths are predictable?

Approximately 1% of the UK population dies each year. Of those deaths, 75% are expected/predictable and 25% are unexpected/unpredictable.

What are the three main trajectories of decline at the end of life identified by Murray et al. (BMJ 2008)?

1. Cancer (n=5)
2. Organ failure (n=6)
3. Physical and cognitive frailty (n=7) (Based on the average 20 deaths each year per UK general practice list of 2000 patients).

What three steps make up the Gold Standards Framework Proactive Identification Guidance (GSF PIG) flowchart?

Step 1: Ask the Surprise Question ('Would you be surprised if the patient were to die in next year, months, weeks, days?'). Step 2: Check for General Indicators of Decline. Step 3: Check for Specific Clinical Indicators.

What criteria are used to identify General Indicators of Decline under the GSF PIG framework?

Looking for 2 or more of the following: poor performance status (needs help with personal care, in bed >50% of the day), 2 or more unplanned admissions, weight loss of 5-10% or BMI < 20, persistent troublesome symptoms, new event or diagnosis, or living in a care home / requiring care at home.

What are the key legal characteristics of an Advance Decision to Refuse Treatment (ADRT)?

It is legally binding provided the person had mental capacity when the decision was made. It only comes into effect when the individual loses mental capacity, can only be used to refuse specific treatments (e.g., IV antibiotics, PEG feeding), and cannot be used to demand a futile treatment.

What are the two types of Lasting Power of Attorney (LPA) and when do they take effect?

1. Property and financial affairs: comes into effect as soon as the LPA is registered.
2. Health and welfare: only comes into effect when the person it applies to lacks mental capacity.

What are the five core principles of the Mental Capacity Act (2005)?

1. A presumption of capacity.
2. Individuals are supported to make their own decisions.
3. People with capacity have the right to make unwise decisions.
4. Anything done on behalf of a person lacking capacity must be done in their best interests.
5. Any best interest intervention must be the least restrictive option possible.

What four questions must be asked when assessing a person's mental capacity for a specific decision?

1. Can this person understand the information relevant to the decision?
2. Can they retain that information?
3. Can they use or weigh that information as part of the process of making the decision?
4. Can they communicate their decision? (If the answer to any of these is 'no', the person is unable to make the decision).

What did the Tracey ruling (Jan 2014) establish regarding resuscitation decisions in Treatment Escalation Plans?

It established that if CPR would not benefit the patient, the decision not to resuscitate is a medical decision rather than a patient choice.

What are the 5 Priorities for Care of the Dying Person?

1. Recognise
2. Communicate
3. Involve
4. Support
5. Plan & do

What physical signs indicate that a patient has entered their last days of life?

Being semi-conscious or unconscious, an irregular or hard-to-detect heartbeat, restlessness/agitation, Cheyne-Stokes breathing, and excess secretions in the upper respiratory tract ('death rattle').

What are four clinical indications for using a syringe driver in palliative care?

1. Altered level of consciousness in a dying patient.
2. Persistent nausea and vomiting (e.g., in bowel obstruction).
3. Inability to swallow.
4. Malabsorption.

What causes excess respiratory secretions ('death rattle') in dying patients, and what non-pharmacological methods manage it?

It is caused by air moving past mucus, saliva, or fluid in the upper airways in unconscious patients who are unable to cough or swallow. Non-pharmacological management includes re-positioning the patient and suctioning.

What three interconnected domains form the Cambridge Breathlessness Intervention Service (CBIS) model?

1. Breathing (inefficient breathing, accessory muscle use, dynamic hyperinflation)
2. Thinking (thoughts about dying, misconceptions, panic, anxiety, distress)
3. Functioning (deconditioning, reduced activity, self-isolation)

In physiotherapy management of dyspnoea, what do the '3 Fs' and '3 Rs' represent?

3 Fs: Fan therapy, Forward lean, Focus on out breath. 3 Rs (Breathing control): Rise (the tummy as you breathe in), Relax (the breath out), Rest (and wait for the next breath to come).

According to Wilcock et al. (2020), when should oxygen be prescribed for breathlessness in palliative care?

Oxygen should only be prescribed to correct hypoxaemia ($SpO_2 < 92\%$) or when other treatment options are ineffective. It should not be used to relieve breathlessness in non-hypoxemic patients.

What are the '4 Ps' of fatigue management in palliative care?

1. Plan
2. Prioritise
3. Performance
4. Pace