End of life care

James talks to Dr David Anderson about end of life care on the wards.

Script Writer:  Duncan Campbell

Summary Writer:  Duncan Campbell

Editor:  James Edwards

Interviewee:  David Anderson

David in an intensive care medicine fellow at RPA Hospital. His interests include end of life care, medical education and pre-hospital care. In addition to intensive care medicine he has spent time training in anaesthesia, retrieval medicine and palliative medicine and before qualifying as a doctor he worked as a paramedic.

End of life care

With Dr David Anderson, Intensive Care Fellow at Royal Prince Alfred Hospital

Introduction

Junior doctors covering the ward after hours are often called to review patients who are dying, or offer support and counselling to the families and loved ones of patients who are dying.

Case 1

You are called by the nurses on the ward to review a patient who has arrived on the ward after being admitted with end-stage COPD. The nurses call you because the patient has a respiratory rate of 50 and looks unwell. They tell you that whilst the patient was in ED, it was decided that she would not be for medical emergency team calls or arrest calls, but this has not been documented. She asks you to complete a Not for CPR order otherwise she will need to make an arrest call.

  • If there is any uncertainty of the patient’s goals of care, they should be treated with curative intent
    until this has been clarified
  • The junior doctor should not complete the Not for CPR order in the absence of any additional information
  • Instead the junior doctor should assess the patient to decide whether an immediate arrest call should be made or whether the patient is stable enough to provide symptomatic relief with oxygen, salbutamol and steroids before urgently contacting someone who knows the patient (either the registrar who admitted the patient, or the attending medical officer)
  • If the attending medical officer tells you definitively that goals of care have been discussed, and that everyone is in agreement that the patient is for comfort care only, it is entirely appropriate to
    document this in the notes and complete the Not for CPR order
  • If these discussions have not been had, or if there is any indecision or lack of consensus between the doctors involved in the patient’s care, you should call for ICU to review the patient (either through a MET call or arrest call)
  • Approach to discussion with the patient
    • Review the patient’s notes and take note of their background including extent of disease, number and regularity of hospitalisations, functional status at home, quality of life
    • Only approach the discussion if the patient is competent and comfortable enough to engage
      in a conversation with you
    • Start by asking the patient their understanding of their illness
    • Most of the time the patient will understand that their chronic disease is worsening, that their life is coming to and end, and will request symptomatic relief only
    • Some of the time the patient will not understand how unwell they are
      • If this is the case, you should introduce the topic sensitively
      • Ensure that the patient understands that there is still a plan in place to provide ongoing treatment, but that the focus of it has changed to symptom relief only
    • If there is no medical consensus about goals of care, or if it is unclear whether the patient is dying or may be able to recover from this deterioration, then it may be appropriate to commence a discussion about goals of care
      • Do not offer the patient every possible treatment- this is known as the tyranny of
        choice
      • Instead the doctor should decide on the best treatment for the patient
      • If there is genuine indecision about which treatment option would be best for the patient, then you should present this to the patient, along with your recommendation
  • Approach to discussion with the family (as surrogate decision makers)
    • Outline the situation to the family
    • Explain that you need to make the best decision for the patient, and that you would like to know what the patient would say if they were competent; ask the family to speak the patient’s wishes
    • If it is clear that the patient is dying, and there is no choice to be made, explain this to the family sensitively, and highlight that any further intervention would not be in the patient’s best interests
  • If the patient is young and has excellent premorbid function, you do not need to have a discussion about goals of care because they will automatically have full resuscitation as required
  • If the patient is clearly dying, and not benefit from resuscitation, you do not need to mention the specifics of not offering chest compressions, intubation, etc. It is sufficient to say that you will focus on comfort care only and then complete a Not for CPR order
  • If the patient is unwell but not dying, it may be necessary to discuss goals of care in more detail, but
    once again it is not helpful to mention specifics. Instead try to frame the options as a choice between symptom relief and making the patient as comfortable as possible vs. an attempt to reverse the causes of this deterioration, but understanding that there may be some things that cannot be reversed
  • Start by acknowledging that this is a very difficult question to answer, and that no one can definitively say exactly how long someone will live
  • Thinking about your own experience looking after similar patients, offer a broad time frame, for example ‘hours to days’
  • If asked, ‘Should I ring the family to come in?’ always say yes
  • Family members will not regret being there, but they might regret not being there

Case 2

You are called by the nurses on the ward to review a patient under the care of the medical oncology team. The nurses tell you that he has a diagnosis of stage IV melanoma with brain metastases and that the team has documented that the patient is for comfort care only, with a valid Not for CPR order at the front of his notes. The patient is now unresponsive but the family is distressed by his noisy breathing, grimaced face and frequent groans.

  • There are two goals:
    • Management of the dying process and ensure that the patient is comfortable
    • Provision of education and support to the family
  • Start by examining the patient to see if there is anything that could be making them uncomfortable
  • Then review the patient’s notes and medication chart to see what medications they have previously been taking
  • In consultation with the medical oncology AT, chart subcut medications to ensure the patient is comfortable
    • Morphine for pain relief
    • Haloperidol for agitation
    • Glycopyrolate for noisy breathing, which is caused by increased secretions
  • Sit down with the family and explain the cause of the noisy breathing, grimaced face and groans, and what medications you can offer to treat these
  • Further reiterate that the patient is dying, and that the time frame is likely to be hours to days and ask the family is there anything else you can do to support them (e.g. chaplain, social worker, palliative care CNC)
  • Empathise with the patient’s wife and family
  • Explain that euthanasia is illegal in Australia
  • Explain that the time frame is out of our hands
  • Remind the family that you will do everything you can to make the patient comfortable
  • Note: there is emerging evidence that the administration of opioids at the end of life does not hasten the dying process, and may in fact prolong it whilst making the patient comfortable

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Tags: #comfort care,#critical care,#death,#DNR,#dying,#end of life care,#not for CPR,#palliative care,#palliative care handbook,#palliative medicine

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