Withdrawing and withholding life-sustaining medical treatment. Currently in the UK it is recognised that where death is inevitable life-sustaining treatments such as resuscitation, artificial ventilation, dialysis or artificial feeding may be withdrawn or withheld. In such cases the goal of medicine becomes the relief of symptoms. ‘Basic care’ and comfort must be provided and can never be withheld.
Removing life-prolonging treatments is not euthanasia It is acknowledged that sometimes giving adequate symptom control or withholding or withdrawing life-prolonging treatments may hasten a death that is already expected. This is not euthanasia.
The journey to relieve suffering and improve quality of life
End-of-life care (or EoLC) refers to health care for a person with a terminal condition that has become advanced, progressive, and/or incurable.
https://en.wikipedia.org/wiki/End-of-life_careTerminal illness or end-stage disease
is a disease that cannot be cured or adequately treated and is
reasonably expected to result in death of the patient. This term is more
commonly used for progressive diseases such as cancer or advanced heart
disease than for trauma. In popular use, it indicates a disease that
will progress until death with near absolute certainty, regardless of
treatment.
https://en.wikipedia.org/wiki/Terminal_illness
Unlike
other conditions and life experiences, which only affect a certain
percentage of the world’s population, the end-of-life is a stage in the
process of living which all people will eventually face.
Tidak seperti kondisi dan pengalaman hidup lainnya, yang hanya mempengaruhi persentase tertentu dari populasi dunia, akhir kehidupan adalah tahap dalam proses kehidupan yang akhirnya akan dihadapi oleh semua orang.
CONVERSATIONS
Conversations about our desires
for end-of-life care are
very uncomfortable for all of us.
We are reluctant to think
about our own mortality,
and that of our loved ones.
Frankly,
it hurts to think about it.
We feel grief
and sadness
when we contemplate life without
that special person,
even if they are with us and healthy.
That fear and sadness is normal.
Avoiding the conversation is
our way of protecting ourselves from pain.
However, avoiding the conversation
when we can so easily have it
only postpones the issue,
and actually makes it harder on us
when we are faced with making care decisions and are unable to
have a discussion.
What are the choices
that we can make?
Each one of us is
faced with a series of decisions
that we make when we consider the end of a life,
be it our own,
or the life a loved one.
Every person has the opportunity
to make decisions about the journey
that they will be on
for the remaining months
or even years of their life.
for end-of-life care are
very uncomfortable for all of us.
We are reluctant to think
about our own mortality,
and that of our loved ones.
Frankly,
it hurts to think about it.
We feel grief
and sadness
when we contemplate life without
that special person,
even if they are with us and healthy.
That fear and sadness is normal.
Avoiding the conversation is
our way of protecting ourselves from pain.
However, avoiding the conversation
when we can so easily have it
only postpones the issue,
and actually makes it harder on us
when we are faced with making care decisions and are unable to
have a discussion.
What are the choices
that we can make?
Each one of us is
faced with a series of decisions
that we make when we consider the end of a life,
be it our own,
or the life a loved one.
Every person has the opportunity
to make decisions about the journey
that they will be on
for the remaining months
or even years of their life.
https://web.archive.org/web/20210107204442/https://healthsocialworktoolkits.weebly.com/uploads/7/8/4/8/78481318/_kokua_mau_hawaii_hospice_and_palliative_care.pdf
Therapeutic communication is a collection of techniques that prioritize the physical, mental, and emotional well-being of patients. Nurses provide patients with support and information while maintaining a level of professional distance and objectivity. With therapeutic communication, nurses often use open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own.
There are a variety opens of therapeutic communication techniques nurses can incorporate into practice.
https://www.rivier.edu/academics/blog-posts/17-therapeutic-communication-techniques/Prepare your family to make decisions for you if you can’t make them at some point in the future.
Knowing what you want will ease the burden on your family of making hard decisions for you if you can’t speak for yourself.
https://bc-cpc.ca/cpc/
These guidelines are intended for inter-professional clinicians working with adults living with advanced life-limiting illness. Though these guidelines were created for adults, the symptoms may also be experienced by children with advanced illness.
https://bc-cpc.ca/cpc/
Our practical, evidence-based programs help health professionals integrate an early approach to palliative care in their routine care for seriously ill patients.
https://bc-cpc.ca/cpc/
The Liverpool Care Pathway for the Dying Patient improves the end of life. The LCP is not a one-way road to death. One in 10 patients initially cared for on the pathway come off it because they improve clinically. Doctors cannot accurately predict the future, and much of what we do in palliative care is based on clinical experience and not hard science. The key to providing good care in this setting is regular review and keeping an open mind, while trying to communicate the uncertainties to the patient's loved ones along the way. The problem is that as a profession we do not communicate with patients and their relatives about this topic well enough. I think it should be routinely discussed as part of our clinical management plans.
LIFE-LIMITING ILLNESS IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/life-limiting-illness-in-palliative.html
An Advance Health Directive is a document that states your wishes or directions regarding your future health care for various medical conditions. It comes into effect only if you are unable to make your own decisions.You may wish your directive to apply at any time when you are unable to decide for yourself, or you may want it to apply only if you are terminally ill.https://www.publications.qld.gov.au/
What is late-stage care?
In
the final stages of a terminal illness, it can become evident that in
spite of the best care, attention, and treatment, your loved one is
approaching the end of their life. At
this point, the focus usually changes to making them as comfortable as
possible in order to make the most of the time they have left.
Depending on the nature of the illness and your loved one’s
circumstances, this final stage period may last from a matter of weeks
or months to several years. During
this time, palliative care measures can help to control pain and other
symptoms, such as constipation, nausea, or shortness of breath. Hospice care can also offer emotional and spiritual support to both the patient and their family.
https://www.helpguide.org/articles/end-of-life/late-stage-and-end-of-life-care.htmGenerally speaking, palliative care offers specialized medical care for anyone living with a serious ailment, with a focus on expert symptom management, skilled communication, and support for patients and their families. It is provided at the same time as all other medical care and its aim is to provide relief from the symptoms and stresses of illness, improving quality of life for both patients and families.
Download pptx
Palliative
care shifts the focus of care from managing the underlying
pathophysiological processes to one that looks at the individual and the
impact of life-threatening illness on them and those important to them. It
aims to prevent and relieve suffering by means of early identification,
assessment, and treatment of pain and other problems, physical,
psychosocial, and spiritual. It focuses on interventions which might
improve an individual’s quality of life rather than alter the underlying
disease process, and routinely extends support to those important to
the individual both during that individual’s lifetime and into
bereavement. Challenges to the provision of effective palliative
care include prognostic uncertainty, the necessity for engaging in
difficult conversations, and the need to deal with a variety of ethical
issues.
https://oxfordmedicine.com/view/10.1093/med/9780198746690.001.0001/med-9780198746690-part-7SUPPORT FOR FAMILIES AND CARERS IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/support-for-families-and-carers-in.html
Care of the Dying Person Key Messages
- Being able to recognise that a person is imminently dying is a crucial step to providing high quality care.
- Care of a person who is imminently dying involves both clinical and ethical considerations but is based on a thorough assessment of current symptoms and forward planning for common problems.
- Care should be based on the needs of the person and the specific clinical context of care.
- Prognostication on the basis of disease trajectory is challenging but important to patient-and family-centred care.
- Withdrawing treatment is a complex and sometimes difficult process and there are guidelines available to help clinicians in this process.
- The most common symptoms in the last two weeks to 24 hours of life are pain and shortness of breath.
PROVIDING A PALLIATIVE APPROACH TO CARE
Futile medical care
Futile medical care is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit.
Some proponents of evidence-based medicine suggest discontinuing the use of any treatment that has not been shown to provide a measurable benefit.
Futile care discontinuation is distinct from euthanasia because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage or hasten the natural onset of death.
https://en.wikipedia.org/wiki/Futile_medical_care
Continued anticoagulation in palliative care patients with limited life expectancy is controversial. Some patients may find daily injections both painful and inconvenient. While therapy can initially provide improvement in symptoms, it may be of limited use at the end of life. Decision to stop anticoagulation therapy must be made on an individual basis by addressing specific goals of care.
https://emedicine.medscape.com/article/270646-overview#showallhttps://diigo.com/0huf91
- "One study of patients with advanced cancer showed that in fact the prevalence of pain actually decreased from 52% about 6 weeks before death to 30% in the last week of life (Conill et al 1997). Perhaps this decrease in pain is because the dying process is one of shutting down, not escalation. Our energy decreases, our alertness decreases and we tend to rest and sleep more.
- Of course, sometimes an individual’s unique circumstances may result in increasing pain in the last weeks of life, however this would be unusual. In such situations, it is imperative that the health care team aggressively pursue comfort with all of the urgency and expertise possible."
Guidelines for the treatment and care of patients towards the end of life.
https://www.eolc.co.uk/professional/guidelines/
Outcomes:
- a) Improve personalised end of life care - enabling more to live and die where they choose.
- b) Reduction of hospitalisation - fewer hospital deaths, fewer crisis and reduced length of stay in hospital.
- c) Symptom control - Improving effective assessment and management of symptoms, including anticipatory planning and management.
- d) Cost effectiveness - Enabling cost effectiveness and cost savings for the NHS
- e) Sustainability - embedding sustained long term changes in practice.
"It is important to understand palliative care is very different from other subspecialties of medicine. It is person-based and not disease- or organ-system-based," Dr. Contreras says. "It's a new paradigm for hospitals because we [palliative care specialists] are of the mind-body-spirit approach. We are not being asked to remove an organ or consult because the kidney is not functioning well. We're being called in because we are trying to improve an ill person's quality of life and address their suffering."A mantra in medicine:
care always, palliate often, cure sometimes.
This may allow patients and their doctors to see healthcare
in a truer light.
https://www.bmj.com/content/345/bmj.e7628.full.pdf
https://www.beckershospitalreview.com/hospital-key-specialties/palliative-care-why-it-has-become-a-growing-specialty-within-hospitals.html
While core palliative care skills can be performed by frontline clinicians including hospitalists, specialty palliative care consults are the ones who are called in for complicated cases.
https://www.the-hospitalist.org/hospitalist/article/121441/hospice-palliative-medicine/10-things-hospitalists-need-know-about
The stress experienced by those working in a HPCU is no greater than in any other palliative care service except in one respect – they are working in a unit within a hospital where there may be little if any understanding of what palliative care is. They will find that what they do is often misunderstood, seen as sentimental and unscientific, but at the same time other nurses and junior doctors in the hospital may envy their job satisfaction in the HPCU.
https://hospicecare.com/what-we-do/publications/getting-started/8-a-hospital-palliative-care-unit
Adjuvant Analgesics - Corticosteroids
- ■ Dexamethasone commonly used
- ■ Works by inhibiting arachidonic acid cascade to reduce inflammation
- ■ Improves appetite, nausea, malaise, and quality of life
- ■ Used for neuropathic pain, cancer pain, bone pain, pain due to compression fractures, headaches, tumors, and malignant bowel obstruction
- ■ Side effects include neuropsychological toxicity, hyperglycemia, fluid retention, gastrointestinal ulcers, fragile skin, weight gain, oral thrush, osteoporosis, and hypertension.
EUTHANASIA
Informational Piece about Euthanasia
The word euthanasia comes from the Greek language.
It means good death.
Sometimes people use the term mercy killing when talking about euthanasia.
Euthanasia or mercy killing is the practice of deliberately ending the life of a person,
often terminally ill, before their natural death occurs.
There are two types of euthanasia:
A. Active or Voluntary Euthanasia:
A terminally ill patient is given medicine
that will kill him/her, usually by a doctor.
Death quickly follows once the drug has been given.
The patients themselves or their legal representative
must request this type of euthanasia.
B. Passive Euthanasia:
Treatment or medicines needed to keep a patient alive are not given
and the patient dies as a result.
Sometimes a patient is being kept alive by machines.
Examples of passive euthanasia would be turning off a machine that is breathing for a patient
or removing a feeding tube from a patient who can no longer eat.
There is an alternative to euthanasia called Physician Assisted Suicide (PAS).
In PAS the doctor participates by prescribing
the necessary drug or combination of drugs that would cause death.
The patient is required to give himself or herself the prescribed medicine
that will end his/her life.
https://web.archive.org/web/20210629121405/http://mssawyerliterature.weebly.com/uploads/3/8/1/8/38188329/__close_reading-_euthanasia.pdf
Informational Piece about Euthanasia
The word euthanasia comes from the Greek language.
It means good death.
Sometimes people use the term mercy killing when talking about euthanasia.
Euthanasia or mercy killing is the practice of deliberately ending the life of a person,
often terminally ill, before their natural death occurs.
There are two types of euthanasia:
A. Active or Voluntary Euthanasia:
A terminally ill patient is given medicine
that will kill him/her, usually by a doctor.
Death quickly follows once the drug has been given.
The patients themselves or their legal representative
must request this type of euthanasia.
B. Passive Euthanasia:
Treatment or medicines needed to keep a patient alive are not given
and the patient dies as a result.
Sometimes a patient is being kept alive by machines.
Examples of passive euthanasia would be turning off a machine that is breathing for a patient
or removing a feeding tube from a patient who can no longer eat.
There is an alternative to euthanasia called Physician Assisted Suicide (PAS).
In PAS the doctor participates by prescribing
the necessary drug or combination of drugs that would cause death.
The patient is required to give himself or herself the prescribed medicine
that will end his/her life.
https://web.archive.org/web/20210629121405/http://mssawyerliterature.weebly.com/uploads/3/8/1/8/38188329/__close_reading-_euthanasia.pdf
GOOD DEATH
What is a good death?
☛ To know when death is coming and to understand what can be expected
☛ To be able to retain control of what happens
☛ To be afforded dignity and privacy
☛ To have control over pain relief and other symptoms
☛ To have choice over where death occurs (at home or elsewhere)
☛ To have access to information and expertise
☛ To have access to spiritual or emotional support
☛ To choose friends, family and community to be with them when they are dying and have time to say goodbye
☛ To be able to issue advance directives that ensure wishes are respected and only appropriate treatments provided
https://web.archive.org/web/20210107192743/https://wnswlhd.health.nsw.gov.au/Downloads/Publications%20and%20Reports/WNSWLHD_Palliative_Care_Plan.pdf
END-OF-LIFE CARE
https://web.archive.org/web/20210107195430/https://www.health.gov.bc.ca/library/publications/year/2013/end-of-life-care-action-plan.pdf
☛ To be able to issue advance directives that ensure wishes are respected and only appropriate treatments provided
https://web.archive.org/web/20210107192743/https://wnswlhd.health.nsw.gov.au/Downloads/Publications%20and%20Reports/WNSWLHD_Palliative_Care_Plan.pdf
END-OF-LIFE CARE
End-of-life care is associated with
advanced,
life-limiting illnesses,
and focuses on comfort,
quality of life,
respect for
advanced,
life-limiting illnesses,
and focuses on comfort,
quality of life,
respect for
personal health care treatment decisions,
support for
support for
the family,
psychological
and spiritual concerns.
psychological
and spiritual concerns.
https://web.archive.org/web/20210107195430/https://www.health.gov.bc.ca/library/publications/year/2013/end-of-life-care-action-plan.pdf
A specialist palliative care inpatient unit
is a specialist unit delivering palliative care services
and can include both free-standing facilities
and wards within a hospital.
Although palliative care services
may be delivered in a range of settings,
numbers of specialist palliative care inpatient units
are reported in this section
due to their specialised role
in palliative care delivery.
https://web.archive.org/web/20210131023555/https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/admitted-patient-palliative-care/hospital-based-facilities-1
A Palliative Approach and End-of-Life care can incorporate many
different activities. As the plan of care is directed by the resident
and family some or all of the activities may apply:
https://web.archive.org/web/20210107203203/http://www.palliativealliance.ca/assets/files/Module_2_Draft.pdf
- ☛ Palliative Care Resource Team
- ☛ Palliative Approach and End-of-Life Care Identification
- ☛ Pain and Symptom Management
- ☛ Emotional Support
- ☛ Spiritual Support
- ☛ Palliative and End-of-Life Care Education (for residents, fami-lies, and staff)
- ☛ Palliative Approach and End-of-Life Care Communication Strategy (for residents, families, and staff)
- ☛ Grief and Loss Support (for residents, families, and staff)
- ☛ Palliative and End-of-Life Care Recreational Activities
- ☛ Advance Care Planning
- ☛ Wound Care
- ☛ Utilizing Community Organization to Support a Palliative Ap-proach and End-of-Life Care Plan
https://web.archive.org/web/20210107203203/http://www.palliativealliance.ca/assets/files/Module_2_Draft.pdf
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
