Critical Care at the End of Life The UK Experience Dr Peter O. Beaumont, MD, MSc, FRCA, FFICM, DIMC Consultant in Anaesthetics and Intensive Care Medicine Senior Lecturer in Paramedic Practice Lead for Patient Transfers, SLACCN (Occasional Prehospital Doctor)

Overarching policies and principles Mental Capacity Act 2005 GMC Good Medical Practice 2017 Guidelines for the Provision of Intensive Care services 2015 NICE: Care of dying adults in the last days of Life 2015 BMA: Policy on physician-assisted dying. 2017

Assessing capacity 4 Criteria Understand information given to them about a particular decision Retain that information long enough to be able to make the decision Weigh up the information available to make the decision Communicate their decision. Assessment indexed to the decision being made

The key principles however are: Every adult is assumed to have capacity until determined otherwise No one can make a decision for another person unless they lack capacity to make the decisions themselves The only persons/bodies who can make significant medical decisions for others who lack capacity are: Lasting powers of attorney (LPA) The judiciary Doctors in charge of a patient’s care (Usually Consultant level in the NHS)

Ceilings of Therapy Colloquial term for Withholding care rather than withdrawal. We will use all treatment that is necessary, “up to a ceiling of” X. Frequently used in the English NHS Often formalised on documents such as: PTEP: Personalised Treatment Escalation Plan DNACPR: Do Not Attempt Cardiopulmonary Resuscitation

Ceilings of Therapy Examples: For Non-invasive ventilation but not for intubation Inotropes to counter sedation, but nothing more Not to go back on mandatory ventilation once weaned For fluid management of AKI, but not for renal replacement therapy

A typical UK family discussion What do you understand has happened and what are we doing for the patient Explain the situation from our point of view including potential outcomes and what they might look like in both short and long term Enquire if the patient had ever expressed any preferences or held formal advanced directives

A typical UK family discussion Enquire what the family believe the patient would want, not what they want for them, if the patient could tell us directly Explain that in absence of an LPA (etc), that the duty/burden to make decisions rests with me/us, and not them. They do not need to feel as though they made the decision If the NoK disagree after a 2nd opinion (we often discuss this amongst ourselves beforehand), then we will support their application to the court for a ruling. I have never seen this done in adult practice.

Withdrawal of Care - practicalities Immediately, on decision to shift the focus of care to palliation: Record the decision and rational in patient notes & complete DNAR form Stop all further tests (except in case of brainstem death testing) Stop all non-essential drugs & prescribe palliative medicines (doctrine double effect) Referral to palliative care team for nearly all cases Offer pastoral support

Withdrawal of Care - practicalities Once family have assembled and said respective words Mute all alarms. Monitor observations remotely if possible Stop renal replacement therapy Stop all inotropes and vasopressors Move ventilator to room air, CPAP 5 and stop pressure support.

Withdrawal of Care - practicalities If oxygen and ventilator requirements are minimal Consider Swedish nose to ETT and remove ventilator Consider extubation and move to simple airway adjuncts (OP/NPA) If after the above is performed death is not imminent, consider transfer to side room on ward, otherwise remain in critical care

Questions and Thank You… Dr Peter O. Beaumont, MD, MSc, FRCA, FFICM, DIMC Consultant in Anaesthetics and Intensive Care Medicine Senior Lecturer in Paramedic Practice Lead for Patient Transfers, SLACCN peter.beaumont3@nhs.net