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

2. “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)

4. A child's prayer for EOLC..

5. Topics
Definitions
Communication
Assisted Suicide
Intervention

6. definitions

7. 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

8. 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

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

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

11. QUALITY

12. Team work…

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

14. 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

15. My role..

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

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

18. 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)

19. Discrepancy of care

20. 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’)

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

23. communication

24. Culturally insensitive…

25. Deceptive…

26. Lacking compassion..

27. Lost the art of medicine..

28. 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

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

31. Baroness Neuberger Report 2013

32. 44 recommendations Stop using LCP & avoid the word ‘pathway’
Senior clinician responsibility
Identifying dying patient
Allowing oral food/water
Good documented communication

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

34. Individual plan of care of the dying patient

35. DNACPR

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

37. Assisted suicide

38. Death of Socrates, 1787

39. 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

40. Palliative Medicine Physicians Survey on Assisted Suicide, 2015

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

42. intervention

43. Mosque clinic

44. Rare Neuro MDT chair

45. Permanent drain for malignant ascites

46. Venting tube for malignant bowel blockage

47. Anaesthetising a palliative patient for chronic insomnia!

48. https://onedrive. live. com/redir. page=view&resid=E5695E33DA4C1B5A

49. Finally..