"Palliative sedation
relieves suffering by lowering consciousness;
Euthanasia does so by terminating life".
The difference between euthanasia and palliative sedation is concisely worded by Broeckaert, who stated the following about palliative sedation: "It is a matter of dying, not killing". The main differences between the two options can therefore be summed up as follows:If practised properly, palliative sedation must be described as a normal medical procedure.
- Palliative sedation relieves suffering by lowering consciousness; euthanasia does so by terminating life.
- Continuous and deep sedation does not in itself shorten life; euthanasia expressly does. Indeed, palliative sedation may even prolong life to some extent (because it prevents exhaustion as a result of suffering).
- Continuous and deep sedation is in principle reversible; termination of life is not.
https://www.oncoline.nl/
ESTIMATING THE PROGNOSIS
Estimating the prognosis helps in the planning
of appropriate treatment and care
— if prognosis is not discussed,
or predictions are inaccurate,
people may make inappropriate treatment decisions,
or inadequately prepare for death.
https://cks.nice.org.uk/topics/palliative-care-general-issues/management/terminal-phase/
Why has the Liverpool Care Pathway been controversial?
According to recent reports,
several families had complained about
the use of the care pathway.
Some relatives claimed that
their loved ones were put on the pathway
without their consent
and some had said it has hastened death
in relatives who were
not dying imminently.
Critics say that
it is impossible for doctors
to predict when
death is imminent,
so the decision to put
a patient on the pathway is
at worst self-fulfilling.
It would be inappropriate
to comment on individual cases.
If there were failings,
as has been alleged,
it could be that these were
the result of professionals
not following the recommendations of the LCP,
rather than faults with the LCP itself.
For example,
the LCP recommendations make it very clear that:
• while legal consent is not required
to place a patient on the LCP,
the fact that the plan is being considered
should always be discussed
with a relative or carer and,
if possible, the patient themselves
• there should never be
an occasion when a relative
or carer who is named as
the main contact is not informed
when a diagnosis that
the person is dying
has been made
• withdrawal of nutrition
and fluids should never be
a routine option,
but done only if it is felt
to be in the best interests
of the patient,
judged on a case-by-case basis
The media has also reported
that use of the pathway is
being encouraged for financial reasons,
linked to targets.
It has been reported
that almost two-thirds of NHS acute trusts
using the LCP have received
“payouts” totaling millions of pounds
for hitting targets related to its use.
While these financial incentives do exist,
they are designed to support
the implementation of better care.
Palliative care e-learning course for healthcare professionals in Africa
The first module introduces you to the core principles of palliative care.
https://ecancer.org/en/elearning/
• Symptom control in patients with chronic kidney disease/ renal impairment is complicated by delayed drug clearance, dialysis effects and renal toxicity associated with commonly used medication (eg. NSAIDs).
• 50% of dialysis patients have pain. Depression and other symptoms are common.
https://web.archive.org/web/20200815173224/https://www.palliativecareggc.org.uk/wp-content/uploads/2015/08/RenalPalliativeCarefinal-mar-2011.pdf
Palliative Care Perspectives from Palliative Care Specialist
• Focused on the idea of a 'good death', achieving that for the patient, and ensuring symptoms are adequately treated -a 'good death' comes in many different forms
• Important factors include supportive family, location, level of care, skilled carers, and specialist support provided at a local level
• Care is an ecosystem -patient and family right at the centre of that, everything else needs to build around that and recognise a cultural/religious/social context
• Important for an individual to be able to recognise they are approaching final 12 months, and to be empowered to have discussions, make decisions about advanced care.
The common symptoms that occur in the dying patient.
1. Pain
2. Nausea and Vomiting
3. Agitation
4. Respiratory Tract Secretions
5. Breathlessness
6. Seizures
Most patients who are dying will experience one or more of these symptoms and will require medication that is administered subcutaneously either PRN or via a syringe driver. The IV or IM routes are not routinely recommended in the dying patient.
Conditions other than those stated above may also be experienced but are considered to be less common and therefore specialist advice is required e.g. Superior Vena Cava Obstruction (SVCO).
Always seek specialist advice for patients with renal impairment or renal failure.
Palliative care is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family.
Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. Palliative care is based on the needs of the patient, not on the patient’s prognosis. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.
https://www.capc.org/about/palliative-care/
The concept of a ‘good death’ is highly contentious. Definitions vary according to different historical and cultural contexts. At certain points in history there has existed formal teaching about the proper conduct of death and dying, perhaps the most noteworthy being the medieval books on ‘the art of dying well’. These were often illustrated with woodcuts showing angels and devils at the deathbed competing for the dying person’s soul. The accompanying inscriptions explain that God and his court are there to observe what happens when the dying person is presented with his or her whole life. The crucial question is whether or not the person yields to despair over his or her sins (Ariès, 1976).
https://www.open.edu/openlearn/health-sports-psychology/social-care-social-work/living-death-and-dying/content-section-1.4.2
End-of-life care should:
o Relieve suffering and preserve dignity
o Be accessible and enable individuals to die in a place of their choice
o Provide care in a culturally and spiritually appropriate manner that is person-centered
o Provide individuals and families with ongoing information to allow informed choice about healthcare preferences and end-of-life care options
o Be supported by organisational governance systems that monitor safety and quality of end-of-life care
o Be provided by healthcare professionals trained to provide appropriate, high quality end-of-life care to individuals and their families
The principles governing analgesic use are summarised
in the WHO Method for Relief of Cancer Pain:
• By mouth, where possible
• By the clock: Regular, as well as p.r.n. dose
• By the ladder:
The patient should be reassessed and analgesia administered in a step-wise manner working up the ladder until the patient’s pain is managed.
Similarly, if the severity of pain is reduced, a patient’s level of analgesics should move back down the ladder, eventually stopping treatment when pain resolves.
Alternative analgesia and adjuvants or non-pharmacological interventions should be considered at each level of the analgesic ladder.
• Individual dose titration: Titrate dose against effect, with no rigid upper limit for most opioids except buprenorphine, codeine and tramadol.
The ethical principles “autonomy, beneficence, non-maleficence and justice” are internationally recognized.
- They are interrelated and have to be applied in the act of medical decision making.
- These bioethical rules have been described by Beauchamp and Childress discussing moral issues since ancient times, for instance in the Hippocratic Oath.
- The four principles are independent of any specific ethical theory and can be applied universally.
- They are an “attempt to put the common morality and medical traditions into a coherent package”.
- Step I — non-opioid analgesics (NSAIDs, non-ste- roid anti-inflammatory drugs) or paracetamol or metamizole;
- Step II — so-called “weak” opioids (tramadol, codeine, and dihydrocodeine);
- Step III — so-called “strong” opioids (morphine, oxycodone, oxycodone/naloxone, fentanyl, buprenorphine, tapentadol, methadone, hydromorphone).
Naloxone
Antidote for opioid sensitivity or overdose induced respiratory depression is Naloxone.
Dilute 400micgrograms in 10ml 0.9% sodium chloride to give a concentration of 40 micgrograms /ml. Administer 40-80microgram naloxone hydrochloride IV bolus every 2-3 minutes up to a maximum of 10mg, until the patient’s breathing and the level of consciousness has improved (if in extremis can use a higher starting bolus such as 200 micrograms). If IV route is not available, naloxone may be administered as IM injection. Dose is always titrated to individual patients condition and rate of reversal.
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0011/306389/liverpoolMorphine.pdf
Help
Me Understand: Palliative
Nursing?
•
Palliative nursing is delivered at the same time
as other curative and life prolonging
treatments, and it is not limited to the
terminally ill.
•
Hospice is a component of palliative nursing
that is focused on the care of the terminally ill
who have opted to stop curative, life prolonging
treatments.
•
The fundamental aspects of palliative nursing
are communication and the coordination of
care within and across various settings.
•
Palliative nursing is the foundation to
respecting patient’s end of life choices.
THE PROVISION OF END OF LIFE CARE
https://pharmacopallcare.blogspot.com/2020/09/the-provision-of-end-of-life-care-ika.html
The provision of End of Life Care involves palliative care, aiming to achieve the best quality of life for patients and their families.
A range of people provide this care, including informal carers, medical, nursing and allied health staff and social care professionals.
The focus of palliative care is teamwork, providing support whatever the setting whether in people’s own homes, hospital, hospice, palliative care unit or care homes.
Palliative Care includes:
☛ Advance Care Planning
☛ Symptom control
☛ Rehabilitation to maximise social participation
☛ Emotional and social support
By focusing on these areas we can help people to have a good quality of life (live well) until they die.
POLICY
Without policies
that support the provision of palliative care
it is quite difficult
for any palliative care to develop.
In some countries
there is no government support
whatsoever for palliative care.
Policy is
therefore seen as the fundamental component,
because without it
other changes cannot be introduced.
Types of policies needed
include:
- ☛ laws that acknowledge and define that palliative care is part of the healthcare system;
- ☛ national standards of care describing palliative care;
- ☛ clinical guidelines and protocols;
- ☛ establishment of palliative care as a recognised medical specialty/ sub-specialty;
- ☛ regulations that establish palliative care as a recognised type of healthcare provider with accompanying licensing provisions;
- ☛ a national strategy on palliative care implementation.
The difficulties
in developing palliative care
and integrating it
into
mainstream service provision
offer evidence
of the obsession on
healing and curing,
as well as
the curative emphasis of modern medicine.
The diagram below illustrates the personal and the health care professional’s care planning status, made in the present or the future
This guidance will be supportive to Advance Care Planning identifying the person’s preferences for and goals of care in the event of a future emergency as well as being inclusive of Anticipatory Clinical Management Plan, which may include treatment escalation plans or ceilings of treatment discussions.
The guidance will also ensure that DNACPR decisions refer only to CPR.
This guidance will provide a framework to ensure that Anticipatory Clinical Management Plans including DNACPR decisions:
☛ Respect the wishes of the individual, where possible
☛ Reflect the best interests of the individual
☛ Provide benefits which are not outweighed by burden.
☛ Record an agreed focus of care
• Do what interests you the most.
— Prof. Feynman (@ProfFeynman) June 19, 2021
• Spend time with nature.
• Ask questions.
• Never stop learning.
• Don't pay attention to what others think of you.
• Read everyday.
• Study hard.
• Teach others what you know.
• Make mistakes and learn.
• It's Okay to not know things! pic.twitter.com/86w7kteYRI
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
