1. Dr Pablo Garcia de Paso Consultant Physician
End of Life decisions
Dr Pablo Garcia de Paso
Consultant Physician

2. Emma was a 31 years old mother of three children: 12y, 5y and 20m.
She had a very supportive parents, sister and brother in law.
Her husband abandoned her and her children.
She worked as a teacher.

3. She was admitted under Neurology on January 2015 due to unsteadiness.
She was diagnosed of paraneoplastic myelitis secondary to Breast Carcinoma.
Initially treated with surgery, chemotherapy and radiotherapy. Already finished long before admission to AMU.
She lost her independence and was full cared by her parents since January A care package was on place.

4. She was receiving community OT and PT and used a wheelchair pushed by others for transferring.
Referred on Feb 2016 to Neuro Rehab Centre (Leamington) as she lost her ability to use the hands. Hence unable to feed herself or her baby daughter.
The aim of that Rehab admission was to recover hand use as much as possible.

5. After two months of admission on the Rehab Centre, she was urgently transfer to AMU on the 3rd May She was very SOB, coughing, febrile and unwell.
She has been treated for two weeks with Meropenem. No improvement.
Notes from chest physio documenting deterioration of the respiratory effort during at least TWO WEEKS prior to transfer.

6. Diagnosis and management
Chest Sepsis secondary to HAP.
T2RF secondary to HAP + muscular failure.
Advanced neurodegenerative disease.
Started on IV Tazocin, IV fluid resuscitation, controlled Oxygen, chest physio, close monitoring with Outreach involvement. Kept on AMU.

7. During the night between the 3rd and the 4th she did not improved but not deteriorated (“holding on”). EWS off the roof. Medical SpR and ITU SpR reviewed her.
On the 4th Consultant review found her extremely unwell, unlikely to survive, not response to treatment in the last 16 hours. Pt and family concerned.
Emma is dying.

8. On the 4th May from 8am to 3pm:
MDT between AMU Cons, ITU Cons and Neuro Cons.
Escalation plan was set and DNACPR was placed.
Conversation happened with family.
Conversation happened with Emma.
Emma’s Solicitor visited to arrange children guardianship to her sister.
Emma’s children were pulled off school and visited her on the ward.

9. On the 4th May from 8am to 3pm:
Active medications were stopped.
Individualised End of Life care plan was placed.
Palliative care team reviewed Emma and family.
Oxygen supply at Emma’s home was arranged.
Anticipatory meds administration was sorted between District nurses and Emma’s father (retired nurse).
Transport booked and patient discharged home.

10. What could have happened before the actions of 4th of May
Arrest call and CPR given:
IOT, femoral stab, another IV access, etc.
Dying with stress, exposure, loneliness, etc.
Emma’s children to go with their biological father.
Parents, sister and children not able to say farewell.
Death and Post death care in the “cold” hospital way.

11. What actually happened
Emma went home and spent her last 24h of life surrounded by her loved ones.
Her children guardianship sorted.
Her preferred place of care (death) granted.
She and her family supported and aware during the dying process.
AN IMPRESSIVE 6 HOURS WORK WHICH CHANGED EMMA’S EXPERIENCE TO THE BEST.

12. Who made the difference
The HCA
The Junior Doctor
The Staff Nurse
The Pharmacyst
The Sister
The Patient
The Discharge coordinator
The Family
Etc.
The Consultant

13. Helping the Dying is everyone responsibility

14. New paradigm

15. How could you make a difference?
Identifying patients who might die in 12m.
Raising concerns about lack of escalation plan.
Asking for a reset of the EWS chart.
Challenging Drs about invasive procedures if unlikely to change outcome.
Talking to patients and families.
Passing on the information: DN, GPs, etc.

16. Identifying End of Life+

17. DNACPR Inform Discuss Confirm ≠ Escalation of care!! No successful
Co-morbidities
No reserve
No successful
Doctor rules
Three
scenarios
Discuss
Not in best interest
Joint discussion
Confirm
Pt’s request
Patient rules
Patient has capacity

18. Documentation

19. Documentation

20. How to get prepared? Remember the aim of Healthcare: Care!
Get to know patient´s wishes: Ask and listen.
Think of patient and family as a whole.
Be empathic and honest.
Holistic care in the four dimensions: physical, emotional, social and spiritual.
Consider after death care as important.
Get ready to dye yourself.

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