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End of life care: Planning for the future

End of life care: Planning for the future. Dr Tom Ratcliffe ST2 GP Manorlands Hospice. Planning for the future. What the GMC requires Different types of plans Making plans in advance Acting on plans Sources of help and information. A case study – Maria.

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End of life care: Planning for the future

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  1. End of life care:Planning for the future Dr Tom Ratcliffe ST2 GP Manorlands Hospice

  2. Planning for the future • What the GMC requires • Different types of plans • Making plans in advance • Acting on plans • Sources of help and information

  3. A case study – Maria • Maria is a 69 year old lady who has just been diagnosed with Alzheimer’s Disease • She is attending the surgery to discuss her diagnosis and plans for the future

  4. A case study – Maria • What are your professional responsibilities in this situation? • When should you raise the possibility of making plans for the future? • How would you go about recording Maria’s wishes? • What are the potential pitfalls? • Where might you turn for advice?

  5. End of Life Care (GMC 2010) • Misunderstandings and conflict at the end of life can be avoided through advance care planning • Advance care planning should be considered when a patient has a life-limiting illness in which capacity to make decisions about treatment may be affected as the illness progresses

  6. End of Life Care (GMC 2010) Discussions should cover: • The patient's wishes, preferences or fears in relation to their future treatment and care • The patient’s feelings, beliefs or values • Details of people that the patient would like to be involved in decisions about their care • Preferences around emergency interventions (i.e. CPR) • The patient's preferred place of care • The patient's needs for religious, spiritual or other personal support

  7. A case study – Maria • Maria has read a lot about her disease and spoken to the Alzheimers Society • She watched her mother, who suffered from dementia, die in hospital with a feeding tube for dysphagia and IV antibiotics for recurrent chest infections • Maria does not want to end her own life in like this...

  8. Making plans – considerations... • Is now the right time? • What does Maria understand about her illness? • Does she want to discuss the future now? • Does she have capacity presently? • Is there anyone else you need to involve in discussions? • What kind of wishes does Maria have?

  9. Types of plan • What kind of plans might it be appropriate to put in place? • Written or verbal advanced care plan (i.e. ‘preferred priorities for care’) • Advanced decision to refuse life-sustaining treatment • Do not attempt CPR order • Appointment of a personal welfare Lasting Power of Attorney

  10. Some ethical and legal issues • Mental Capacity Act 2005 • Makes provisions for advance planning • Stipulates that when a patient lacks capacity doctors must act in the patient’s best interests with due regard to the patient’s: • past and present wishes and feelings • values and beliefs that would be likely to affect decisions • other factors the patient might consider were they able to do so

  11. Some ethical and legal issues • An advance directive is not valid if: • The patient has capacity • A person with lasting power of attorney has been appointed • A capacitous decisions has been made to withdraw the directive • The patient has done something that is clearly inconsistent with the advance directive • The current treatment or circumstances are not covered by the directive • There are grounds for believing that there are circumstances not anticipated by the patient

  12. Some ethical and legal issues • An advance decision to refuse life-sustaining treatment is only valid if... • The patient lacks capacity • The decision is recorded in writing • It is signed by the patient and a witness • It includes the statement ‘even if life at risk’

  13. Maria – example MY ADVANCE DECISION TO REFUSE TREATMENT My name: Maria Smith Address: 14 Smith St, Keighley I have written this document to identify my advance decision. These are my decisions about my healthcare, in the event that I have lost my mental capacity and cannot consent to or refuse treatment.

  14. Some pitfalls... • Advance refusal of certain treatments leads to poorer quality of life (i.e. refusal of mechanical ventilation leading to hypoxic brain damage) • Refusal of simple treatments could lead to greater distress (i.e. untreated urinary tract infection in patient with dementia) • Insistence on only being kept comfortable after a particular event might restrict opportunities for rehabilitation (i.e. requesting comfort only measures after a stroke)

  15. Acting on plans • Make sure the plan is still valid • Use the NHS End of Life Care checklist • Remember that even if a plan is not valid it may provide some indication about a patient’s values, beliefs and wishes that can be used to decide what course of action is in a patient’s best interests

  16. Sources of information • Royal College of Physicians: Advance Care Planning National Guidelines (2009) • General Medical Council: End of Life Care (2010) • NHS End-of-life Care: National Council for Palliative Care Advance Decisions to Refuse Treatment A Guide for Health and Social Care Professionals (2008) • Societies specialising in different diseases (i.e. Alzheimer’s Society) • Local hospice and palliative care team

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