Presentation on theme: "Professor D. Robin Taylor Wishaw General Hospital"— Presentation transcript:
1Professor D. Robin Taylor Wishaw General Hospital CEILING OF TREATMENTProfessor D. Robin TaylorWishaw General Hospital
2Case study Male, 78 years, end-stage COPD Several admissions for over the previous year.Admitted with bronchopneumonia and respiratory failure.End of life conversation between myself, the patient and his family at 4pm. Acknowledged to be terminally ill.Agreed that medical treatment would be limited to oxygen, fluids, lorazepam, and morphine. This was documented.At 3 a.m. next morning, nursing staff noted the patient to be more breathless. In response, the on-call registrar commenced non-invasive ventilation (NIV) and aminophylline.Patient died 4 hours later. Family very angry.
4Ceiling of TreatmentCommon senseCommunicationCompassion
5Ceiling of TreatmentWhen are decisions …Futile and /orBurdensome and / orContrary to the patient’s wishes?
6Ceiling of TreatmentDesigned …To improve management of acute episodes of deterioration in the context of an end-of-life trajectory.For use in hospitals to provide continuity of care and good communication.To provide information about, as well as appropriate limitations to interventions which are likely to be futile, burdensome, or contrary to the patient’s wishes.To be guided by discussions with patient and family or POA.To complement an Anticipatory Care Plan (ACP).
7Ceiling of Treatment (Respiratory) Assuming that other immediately reversible problems have beenaddressed (e.g. pneumothorax), management of the patient’sacute respiratory distress SHOULD ALWAYS INCLUDE SYMPTOMRELIEF e.g. low flow oxygen, opiates, haloperidol, benzodiazepine.Thereafter, the patient’s ACUTE MANAGEMENT MAY INCLUDE THEFOLLOWING: (Circle YES or NO. Changes can be made at any timelater if necessary).ARTERIAL BLOOD GAS ANALYSIS YES / NOANTIBIOTICS YES / NOPREDNISOLONE YES / NONON-INVASIVE VENTILATION (BiPAP) YES / NOTRANFER TO HIGH DEPENDENCY UNIT YES / NOICU / POSSIBLE MECHANICAL VENTILATION YES / NOCPR IN THE EVENT OF CARDIO-RESPIRATORY ARREST YES / NOActive consideration should be given to the need for spiritual care. ThisDocument should be used in conjunction with the Scottish National Guideline forPalliative Care in the Last Days of Life.Ceiling of Treatment (Respiratory)
8Ceiling of Treatment: NHS Lanarkshire Piloted in Ward 7, WGHNow configured forCardiologyGastroenterology (Liver Disease)Advanced MalignancySurgeryHECT team study now under wayMedical and nursing training now under way
9Reference: Taylor D.R. COPD, end of life and Ceiling of Treatment Thorax 2014; 69: 497-499.