End of life care (eolc) Dr Nicholas Herodotou Macmillan Consultant Palliative Medicine (Cambridge Community Services) L&D University Hospital

“To everything there is a season, A time for every purpose under heaven: A time to be born, And a time to die.” (Ecclesiastes 3:1–2)

A child's prayer for EOLC..

Topics Definitions Communication Assisted Suicide Intervention

definitions

History of hospice movement Latin ‘hospis’ meaning guest Early church cared for poor and dying Modern hospice movement, Dame Cecily Saunders, 1967, St Christopher’s hospice Focus on holistic symptom management of palliative patients & carers using a Multi-Disciplinary Team (MDT) approach

Definition of palliative care Holistic multidisciplinary care of patient & family suffering from a progressive, incurable, life limiting illness. Aim is to give quantity and NOT quantity to their life Physical, psychological, social & spiritual

Prognostic Indicator Guidance (PIG) 4th Edition Oct 2011 © The Gold Standards Framework Centre In End of Life Care CIC, Thomas.K et al

Extracted from More Care Less Pathway, a Review of the LCP

QUALITY

Team work…

Team members… Doctor/Mac Nurse Support workers Palliative Patient Discharge team Social worker Psychology Chaplain Dietician OT/Physio

Hospice: doctors Nurses Social worker Volunteers Day unit Hospital: Mac nurses Consultant Discharge team Chaplin Community: Macmillan nurses Support workers Primary care: District nurses GP

My role..

Hospital & community patients Ethical decision making Support to hospital/community/GP Teaching Interventions

Palliative patients include… Cancer Neurological conditions: MND, MS Heart failure Lung disease: Advanced dementia

Why non-cancer? Non-cancer dying patients were dying badly Discrepancy of care: over focus on cancer End of Life Care (EOLC) strategy 2008: Identifying cancer & non- cancer patients in last year of life Advanced Care planning(ACP) Liverpool Care Pathway (LCP)

Discrepancy of care

Advanced Care Planning (ACP) Advance statements to inform subsequent best interests decisions Advance decisions to refuse treatment which are legally binding if valid and applicable to the circumstances at hand (Living Will) Appointment of Lasting Powers of Attorney (‘health & welfare’ and/or ‘property and affairs’)

When is a person dying? Less energy Semi-conscious Clinically deteriorating Francis I at the dying Leonardo da Vinci by Louis Gallait

communication

Culturally insensitive…

Deceptive…

Lacking compassion..

Lost the art of medicine..

But… “If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.” Nelson Mandela

Liverpool Care Pathway (LCP) problem.. Poor communication by consultants Misunderstanding of the LCP Not identifying the dying patient Huge complaints therefore…

Baroness Neuberger Report 2013

44 recommendations Stop using LCP & avoid the word ‘pathway’ Senior clinician responsibility Identifying dying patient Allowing oral food/water Good documented communication

Replacing the LCP? National template Individualised Care plan Clearer documented communication

Individual plan of care of the dying patient

DNACPR

Preparing for a natural death Administration of the Eucharist to a dying person (painting by19th-century artist Alexey Venetsianov)

Assisted suicide

Death of Socrates, 1787

Recent MP vote on Assisted Dying 330 against vs 118 for Bill was to allow terminally ill patients < 6 months to live to be helped to die Two independent doctors to sign form Competent, not depressed, not coerced Eleven attempts in 12 yrs. to change law in parliament on Assisted Dying

Palliative Medicine Physicians Survey on Assisted Suicide, 2015 http://apmonline.org/wp-content/uploads/2015/05/Assisted-Suicide-Survey-Quantitative-Results-.pdf

Lessons from Belgium.. 50% euthanasia nurses killed without consent 50% cases unreported Euthanasia patients used as organ donors Euthanasia for children just passed

intervention

Mosque clinic

Rare Neuro MDT chair

Permanent drain for malignant ascites

Venting tube for malignant bowel blockage

Anaesthetising a palliative patient for chronic insomnia!

https://onedrive. live. com/redir. page=view&resid=E5695E33DA4C1B5A https://onedrive.live.com/redir?page=view&resid=E5695E33DA4C1B5A!5560&authkey=!AHnjr2iskHPEJCc

Finally..