Professor D. Robin Taylor Wishaw General Hospital CEILING OF TREATMENT Professor D. Robin Taylor Wishaw General Hospital

Case 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.

Nobody documented what not to do!

Ceiling of Treatment Common sense Communication Compassion

Ceiling of Treatment When are decisions … Futile and /or Burdensome and / or Contrary to the patient’s wishes?

Ceiling of Treatment Designed … 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).  

Ceiling of Treatment (Respiratory) Assuming that other immediately reversible problems have been addressed (e.g. pneumothorax), management of the patient’s acute respiratory distress SHOULD ALWAYS INCLUDE SYMPTOM RELIEF e.g. low flow oxygen, opiates, haloperidol, benzodiazepine.   Thereafter, the patient’s ACUTE MANAGEMENT MAY INCLUDE THE FOLLOWING: (Circle YES or NO. Changes can be made at any time later if necessary). ARTERIAL BLOOD GAS ANALYSIS YES / NO ANTIBIOTICS YES / NO PREDNISOLONE YES / NO NON-INVASIVE VENTILATION (BiPAP) YES / NO TRANFER TO HIGH DEPENDENCY UNIT YES / NO ICU / POSSIBLE MECHANICAL VENTILATION YES / NO CPR IN THE EVENT OF CARDIO-RESPIRATORY ARREST YES / NO Active consideration should be given to the need for spiritual care. This Document should be used in conjunction with the Scottish National Guideline for Palliative Care in the Last Days of Life.     Ceiling of Treatment (Respiratory)

Ceiling of Treatment: NHS Lanarkshire Piloted in Ward 7, WGH Now configured for Cardiology Gastroenterology (Liver Disease) Advanced Malignancy Surgery HECT team study now under way Medical and nursing training now under way

Reference: Taylor D.R. COPD, end of life and Ceiling of Treatment Thorax 2014; 69: 497-499.