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Dying at home. Practical aspects for the GP. Birth is a miracle; death is a mystery. Neither fit easily into a biomedical model. Home birth. Not really planned for a labour “Thought we would see when the time comes” not sure how to diagnose labour, anyway

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dying at home

Dying at home

Practical aspects for the GP

Dr Eileen Palmer West Cumbria Hospice at Home

birth is a miracle death is a mystery neither fit easily into a biomedical model

Birth is a miracle; death is a mystery. Neither fit easily into a biomedical model.

Dr Eileen Palmer West Cumbria Hospice at Home

home birth
Home birth
  • Not really planned for a labour “Thought we would see when the time comes”
  • not sure how to diagnose labour, anyway
  • not discussed care environment/suitability, even with midwife
  • no delivery pack/pain relief in the home

Dr Eileen Palmer West Cumbria Hospice at Home

home birth4
Home birth
  • the care environment
  • the lay carers
  • the professional carers (the midwife)
  • the safety net
  • anticipating ‘planning for common problems

rapid, easy access to:

  • :medication (including out of hours)
  • equipment (including out of hours)
  • medical and nursing staff (including out of hours)
  • information and support for patient
  • and carers

Dr Eileen Palmer West Cumbria Hospice at Home

home death
Home death
  • Not really planned where the death might be. “Thought we would see when the time comes”
  • not sure how to diagnose dying, anyway
  • not discussed care environment/suitability, even with District Nurse
  • no equipment/ basic medication/pain relief in the home

Dr Eileen Palmer West Cumbria Hospice at Home

home death6
Home Death
  • the care environment
  • the lay carers
  • the professional carers (the district nurse)
  • the safety net
  • anticipating and planning for common problems

rapid, easy access to:

  • :medication (including out of hours)
  • equipment (including out of hours)
  • medical and nursing staff (including out of hours)
  • information and support for patient and carers

Dr Eileen Palmer West Cumbria Hospice at Home

home death7
Home death
  • Decision around the place of death
  • Diagnosing that the patient is dying
  • Anticipating and planning for common problems at home
  • Prescribing and ensuring access to core drugs
  • Ongoing nursing care
  • Communication/out of hours care

Dr Eileen Palmer West Cumbria Hospice at Home

deciding on a home death
Deciding on a home death
  • The patient’s wishes
  • the care environment
  • the carers
  • the professional support:

Dr Eileen Palmer West Cumbria Hospice at Home

the care environment
The care environment
  • A telephone (or mobile)
  • facilities for personal care
  • an intercom/baby monitor/handbell for attracting attention
  • a bed
  • (safety for staff)

Dr Eileen Palmer West Cumbria Hospice at Home

the carers
The carers

Do they:

  • exist?
  • feel able to do it and
  • have adequate physical strength
  • have adequate emotional resource
  • Have access to practical help.
  • Know what help is available and how to access it

Dr Eileen Palmer West Cumbria Hospice at Home

the professional support
The professional support
  • District nurse
  • Marie Curie nursing services
  • Macmillan carer schemes
  • Hospice at Home schemes
  • Macmillan nurses
  • safety nets

Dr Eileen Palmer West Cumbria Hospice at Home

goals of care change

Goals of care change

A carer’s story

Dr Eileen Palmer West Cumbria Hospice at Home

goals of care change for the dying patient
Goals of care change for the dying patient:
  • to die in a place of their choice (usually home)
  • to be free of unpleasant symptoms
  • dignity
  • closeness with and support of family
  • spiritual care/peace of mind

Dr Eileen Palmer West Cumbria Hospice at Home

goals of care change for the medical and nursing team
Goals of care change for the medical and nursing team
  • Discontinuing non essential care (including medication)
  • easy access to comfort care (including medication)
  • care of family unit
  • attention to spiritual care needs

Dr Eileen Palmer West Cumbria Hospice at Home

anticipating and planning for common problems at home 1
Anticipating and planning for common problems at home (1)
        • Loss of mobility
  • Unable to transfer safely
  • Loss of ability to eat
  • Loss of ability to drink
  • Loss of ability to swallow

Dr Eileen Palmer West Cumbria Hospice at Home

anticipating and planning for common problems 2
Anticipating and planning for common problems (2)
  • Delirium and agitation
  • Pain
  • Vomiting
  • Dyspnoea
  • Excess respiratory secretions
  • Changing breathing pattern

Dr Eileen Palmer West Cumbria Hospice at Home

nursing care
EQUIPMENT

Rapid access to:

bed/mattress

commode

catheterisation pack

intercom

syringe driver

nebuliser

portable suction

NURSING CARE

comfort care only

care of eyes and mouth

personal care for dignity

continence needs

symptom monitoring/medication

carer support

Nursing care

Dr Eileen Palmer West Cumbria Hospice at Home

medical care discontinue non essentials
Medical care: discontinue non essentials
  • XR’s, blood tests, IV infusions
  • explain absence of need for CPR/calling an ambulance at point of death
  • most medication (including anti-anginals, anticoagulants, anti-hypertensives, anti-diabetics, etc. etc.)

Dr Eileen Palmer West Cumbria Hospice at Home

medical care continue essentials
Medical care: Continue essentials
  • CONTINUE:

Frusemide for heart failure (give as S/C injection)

Anticonvulsants replace with midazolam 30mg/24 h. Increase to 40mg, then 60mg if still pre-ictal. Have midazolam/diazepam in the home.

Dr Eileen Palmer West Cumbria Hospice at Home

medical care prescribe the core four
Medical care: Prescribe the core four
  • An analgesic: Rx DIAMORPHINE
  • An anti-emetic: Rx CYCLIZINE
  • An anti-secretory: Rx HYOSCINE HYDROBROMIDE
  • A sedative: Rx MIDAZOLAM

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing the core four
Prescribing the core four

Dr Eileen Palmer West Cumbria Hospice at Home

what about syringe drivers
What about syringe drivers?

PRO-ACTIVE PROVISION or rapid access:

  • in the home
  • in the Cuedoc car
  • in a “Palliative care bag

PRO-ACTIVE PRESCRIBING

  • not a panacea

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing for the syringe driver pain
Prescribing for the syringe driver: PAIN
  • On no oral opioid Diamorphine 10mg/24h
  • On oral morphine Divide 24h morphine dose by 3 = mg diamorphine/24h
  • On fentanylLEAVE THE PATCH ON. Prescribe additional diamorphine using the guideline
  • On other opioids Refer to the conversion chart/contact the specialist team

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing for the syringe driver pain28
Prescribing for the syringe driver:PAIN

PRESCRIBE ADDITIONAL PRN PAIN RELIEF:

RX one sixth of 24h diamorphine dose stat, then prn for pain.

(The syringe driver takes 4h to build up a serum level)

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing for the syringe driver vomiting
Prescribing for the syringe driver:VOMITING

Rx cyclizine 150mg/24h

(or Nozinan 12.5mg/24h)

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing for the syringe driver xs secretions
Prescribing for the syringe driver:XS SECRETIONS

Rx hyoscine hydrobromide 1.6-2.4mg/24h

or glycopyrrollate 0.8-1.2mg/24h)

(positioning/suction)

Dr Eileen Palmer West Cumbria Hospice at Home

prescribing for the syringe driver agitation restlessness
Prescribing for the syringe driverAGITATION/RESTLESSNESS

Rx Midazolam 5-30mg/24h

(Check bedsheets

bladder

pain control)

Dr Eileen Palmer West Cumbria Hospice at Home

the golden rules for syringe drivers
The golden rules for syringe drivers:
  • Divide by three
  • Remember loading dose and prn’s
  • DON’T remove the patch
  • DON’T use the boost button
  • DON’T add extra drugs to a driver that is running

Dr Eileen Palmer West Cumbria Hospice at Home

mixing drugs in syringe drivers
Mixing drugs in syringe drivers:
  • Diamorphine
  • cyclizine
  • haloperidol
  • metoclopramide
  • levomepromazine
  • hyoscine HBr
  • midazolam

USUALLY FINE

Dr Eileen Palmer West Cumbria Hospice at Home

watch out for problems with
Watch out for problems with:
  • Cyclizine once diamorphine dose exceeds 200mg
  • Ketorolac
  • Dexamethasone

Dr Eileen Palmer West Cumbria Hospice at Home

out of hours care for dying patients

Out of hours care for dying patients

Tom’s story

Dr Eileen Palmer West Cumbria Hospice at Home

out of hours care
Out of hours care
  • Two thirds of the week is “out of hours”
  • 105.5 hours /week vs 52.5 hours/week “in hours”
  • a weekend (1830 Friday-0800 Monday) may need 10 shifts of doctor (14 For Bank hols)

Dr Eileen Palmer West Cumbria Hospice at Home

out of hours care37
Out of hours care

Challenges accessing:

  • Basic patient information
  • District Nurses
  • Specialist nurses
  • Other specialist resources
  • equipment/syringe drivers
  • pharmacists
  • medication

Dr Eileen Palmer West Cumbria Hospice at Home

out of hours palliative care for the dying
Out of hours palliative care for the dying
  • Effective identification of dying patients by the practice
  • effective handover system from “in-hours” to “out of hours” care (and back again)
  • Out of hours doctors/ nurses are trained to care for dying patients
  • Out of hours service provider is properly equipped
  • PRO-ACTIVE “IN HOURS” CARE: CRISIS AVOIDANCE

Dr Eileen Palmer West Cumbria Hospice at Home

accessing drugs out of hours 1
Accessing drugs out of hours (1)
          • The commonest drugs needed out of hours are:
  • Diamorphine 10mg, 30mg and 100mg injection
  • Cyclizine 50mg injection
  • Haloperidol 5mg injection
  • Metoclopramide 10mg injection
  • Levomepromazine (Nozinan) 25mg injection
  • Midazolam 10mg injection
  • Hyoscine hydrobromide 400mcg injection (or glycopyrrollate 0.4mg/2ml injection)
  • Water for injections

Dr Eileen Palmer West Cumbria Hospice at Home

accessing drugs out of hours 2
Accessing drugs out of hours (2)
          • Less commonly used are
  • Dexamethasone 20mg/5ml injection
  • Diazepam rectal 10mg or 10mg/2ml IV injection
  • Ketorolac 30mg/ml injection
  • Oxygen

Dr Eileen Palmer West Cumbria Hospice at Home

accessing drugs out of hours 3
Accessing drugs out of hours (3)
  • “emergency pack” prescribed and left in the home
  • named community pharmacists carrying a stock (and providing rapid access on-call)
  • Basing emergency packs in community hospitals, hospices, OOH service provider bases.
  • Carrying a “palliative care kit” in the OOH service car

Dr Eileen Palmer West Cumbria Hospice at Home

spiritual care
Spiritual care
  • Kindness and compassion
  • Deep listening
  • involving spiritual care workers appropriately
  • looking after ourselves and each other

Dr Eileen Palmer West Cumbria Hospice at Home

slide44

Home

Dr Eileen Palmer West Cumbria Hospice at Home

to summarise
To summarise
  • BE PROACTIVE
  • PRESCRIBE THE CORE FOUR
  • for every 5 minutes talking, spend 10 minutes listening and 15 minutes ensuring good communication across teams
  • THIS IS REAL MEDICINE

Dr Eileen Palmer West Cumbria Hospice at Home