Wirral End of Life Care Charter
CARE, KINDNESS AND UNDERSTANDING
End of life care:
• Is the total care of a person with an advanced, progressive, incurable illness or frailty;
• Is not just about dying;
• May last a few days, or for months or years;
• Begins when, and continues as long as, it is needed.
You May Expect:
Support by skilled and
knowledgeable staff that
recognises your situation &
who work together to coordinate
& manage your care.
With your permission that
plans, if you have made any,
are shared with those
involved in your care, so that
your wishes may be fulfilled.
That, if you wish, those
who are important to you
are involved in decisions
about your care & treatment.
Care which includes what
you eat & drink, control with
your symptoms, and support
with your emotional, social,
cultural, and spiritual needs.
Regular reviews of your
individual care plans that will
meet your needs and include
decisions & actions that are
made to best fit your wishes.
The possibility that you
may die within the next
few days or hours is
communicated clearly &
sensitively, to you & those
who are important to you.
The support of trained staff,
who will help you to think &
plan ahead, if you want, to
discuss your preferences &
wishes for your care.
Support to help keep your
independence as long as
possible by caring staff
respecting your dignity &
sense of control throughout
your illness.
The needs of your family &
others important to you are
respected & met, as far as
possible.
That you, & others
important to you, will be
treated with compassion &
respect towards the end of
your life.
That your body will be
treated with dignity &
respect after your death.
That during your illness &
after your death, those
important to you, receive
practical, emotional &
spiritual support.
THE WAY THAT WE LOOK AFTER PEOPLE WHO ARE DYING IS IMPORTANT
The way
that we look after people
who are dying
is important.
Good care
at the end of life
can help to reduce distress
and grief for the person
who is dying
and for their
family,
friends
and carers.
It is important
that you are involved
in making choices
about your care
at the end of life.
This means
working with clinicians
to understand your situation,
thinking about
who you would like
to be involved
in making decisions
about
your care,
and nominating someone
to speak for you
if you are
no longer able to
communicate
for yourself.
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https://txpeds.org/palliative-care-toolkit?qt-palliative_care=5#qt-palliative_care
Together for Health - Delivering End of Life Care
http://www.wales.nhs.uk/palliativecare
Palliative Care in Heart Failure
Rationale, Evidence, and Future Priorities
PALLIATIVE CARE IN HEART FAILURE
https://pharmacopallcare.blogspot.com/2020/09/palliative-care-in-heart-failure-ika_26.html
DEPRESCRIBE
‘Deprescribing
is an active process of tapering,
withdrawing,
discontinuing
or stopping medicines
to reduce potentially problematic polypharmacy,
adverse drug effects
and inappropriate
or ineffective medicine use
by regularly re-evaluating the ongoing reasons for,
and effectiveness of medication therapy’*
Deprescribing forms
a part of comprehensive medication review.
The overall goal of deprescribing is
to maintain or improve quality of life.
*Deprescribing: A Practical Guide Version 2.0 September 2017 - Developed by the NHS Southern Derbyshire CCG Medicines Management Team.
The most common classes of medications where there is often great opportunity to ”deprescribe” in the Palliative setting with a high likelihood that the benefit (including just reducing the pill “burden” and reducing cost of care) outweighs the harm include:
☛ 1. Dementia medications – anticholinesterase inhibitors and memantine
☛ 2. Statins
☛ 3. Anticoagulants and aspirin
☛ 4. Anti-hypertensives
☛ 5. Insulin and oral hypoglycemics
☛ 6. Vitamins, iron supplements, calcium
RAISED INTRACRANIAL PRESSURE
- ☛ This may be due to direct tumour pressure or surrounding cerebral inflammation.
- ☛ Headache, vomiting, confusion and blurred vision may occur.
- ☛ Steroids reduce oedema around the tumour.
- ☛ Dexamethasone 8mg bd may give a response within 24 hours. Apart from hydrocortisone, give oral corticosteroids no later than midday to reduce insomnia.
- ☛ In those with a history of gastrointestinal problems, or already on an NSAID for other reasons, provide gastroprotection with a proton pump inhibitor.
- ☛ After 4-5 days, reduce dose by one quarter per week to the minimum effective maintenance dose, to minimise side effects.
- ☛ Benefit may persist for 1-2 months.
- ☛ If no response after 7 days, reassess.
Bowel obstruction
Bowel obstruction is due to mechanical obstruction (partial or complete) of the bowel lumen and/or peristaltic failure. Can be complex to manage and requires specialist advice. Bowel obstruction should be managed in a multidisciplinary way and it may be relevant to seek the views and review of a surgical team (if surgery is contemplated), oncologists and palliative care (dependent on the setting).
Medication
Peristaltic failure
- ☛ May be due to autonomic neuropathy or intra-abdominal carcinomatosis. Partial obstruction, reduced bowel sounds, no colic.
- ☛ Stop medication reducing peristalsis (cyclizine, hyoscine, 5HT3 antagonists, amitriptyline).
- ☛ Use a prokinetic anti-emetic, for example SC †metoclopramide 30mg to120mg/24 hours; stop if colic develops. Caution in use of prolonged higher doses, monitor for extrapyramidal side effects.
- ☛ Laxatives are often needed. Refer to constipation guideline.
- ☛ Balance analgesic needs against the risk of poor oral absorption. If a syringe pump is required then morphine or diamorphine would be considered in the first instance.
- ☛ However, in the longer term, a fentanyl patch may provide a less invasive approach.
- ☛ Fentanyl patch for controlling stable, moderate to severe pain in patients with/or at risk of peristaltic failure is less constipating than morphine or oxycodone.
Mechanical obstruction
- ☛ Target treatment at the predominant symptom(s).
- ☛ Laxatives (+/- rectal treatment) to treat/ prevent co-existent constipation. Laxido (if volume of fluid is tolerated) is effective. †Docusate sodium is an alternative. Avoid stimulant laxatives (senna, bisacodyl, danthron) if patient has colic. Stop all oral laxatives in complete obstruction.
- ☛ †Dexamethasone (6mg to 16mg) parenterally for 4 to 7 days may reverse partial obstruction. Refer to †Dexamethasone guideline for administration guidance.
Practice points
- ☛ When using sedating medication, consider starting at lower doses.
- ☛ Most patients need an SC infusion of medication as oral absorption is unreliable.
- ☛ Review treatment regularly; symptoms often change and can resolve spontaneously.
- ☛ Do not combine anticholinergic anti-emetics (cyclizine, hyoscine) with metoclopramide. Caution in use of prolonged higher doses, monitor for extrapyramidal side effects. Refer to guidelines for Subcutaneous Medication, Nausea and Vomiting, Levomepromazine.
Constipation: Medication
- ☛ Always prescribe a laxative when commencing opioids
- ☛ Stimulant laxatives - increase peristalsis (gut motility) in large bowel and can cause cramps (Senna). Bisacodyl and Dantron work on both small and large intestine.
- ☛ Softeners - lubricate the faeces and ease passing (Docusate)
- ☛ Osmotic laxatives - draw water into the large bowel which encourages peristalsis and softens the faeces (Movicol/Lactulose)
- ☛ Bulk forming laxatives - increase volume of faeces by increasing the fibre in the diet (useful in chronic constipation, less useful in palliative care) (Fybogel)
ROLE OF STEROIDS
- ☛ The treatment targets three basic pathophysiologic consequences of MBO (Malignant Bowel Obstruction) i.e. cascade of secretion, distension and bowel hypertonia associated with MBO.
- ☛ Corticosteroids have been prescribed in palliative therapy since the late 1950’s.
- ☛ They can be given by various routes including intravenous (i.v.), subcutaneous (s.c.), oral and rectal.
- ☛ The commonly used steroids include dexamethasone and methylprednisolone.
- ☛ The bioavailability of oral administration of dexamethasone is 80%.
- ☛ Anti-inflammatory potency of dexamethasone is 5-10 times as that of methylprednisolone.
The goal of #PalliativeCare is to improve quality of life. for living with many disease types and chronic illnesses. These include #cancer, #cardiac disease like #CHF, #COPD, #kidneyfailure, #Alzheimers, #Parkinsons, #ALS, #COVID19 and many more. pic.twitter.com/AvIZKYoO5V
— Get Palliative Care (@GetPalliative) July 19, 2021
Okay kan, Bro!
IKA SYAMSUL HUDA MZ
