1. Case Discussions Challenges in End of Life Care 15/11/14 MRS M

2.  85 year old Care Home Resident  Type 2 diabetes, leg ulcer  Meds:  PPI Statin, Metformin, + recent Amitriptyline, MST, Oramorph  Social  Orientated, alert, communicates with staff  NOK – Nephew

3. Background  Foot ulcer 6/12 care of DNs but mobile  8 th June: …lost weight, poor appetite, worsening foot pain  Commenced MST, + Oramorph prn  Late June: Still pain ?Neuropathic- Amitriptyline commenced  Due review 1 st July by Community Geriatrician for A CP

4. 30 th June – phone call – on call GP, Mon 2pm  “Mrs M deteriorated over morning, not herself ”  Visit  In Bed, Difficult to rouse  All Obs normal  Looked Dry. General exam NAD  Pupils reacting- Not co-operative for neuro exam,  No obvious infection…… No urine to test  LOOKED LIKE SHE WAS DYING

5. WHAT DO YOU DO NOW?  ADMIT OR LEAVE IN NURSING HOME??  Staff want admission unless GP does DNACPR form and ACP immediately  Nephew in a meeting. Staff say spoken to him. He would be keen for admission. Not able to disturb until meeting ends at 7pm  Note – was due to have ACP discussion in a few days.

6. Discussion  Unable to ask Mrs M her wishes  No prior discussion recorded (due imminently)  No family available to ask what Mrs M would have wished  Patient best interests..  Benefits v burdens of courses of action.

7. WHAT HAPPENED NEXT?  Arranged admission as sudden change even though appeared end of life…… Ambulance booked  Nursing home staff happy, GP troubled.  Later… Nursing Home phoned- managed to contact nephew who preferred to leave Mrs M in Home  Unable to take anything orally, sub cutaneous meds arranged  2/7 died peacefully surrounded by family