1. Jo Swallow and Mary Valentine GP Educators. F2 teaching session Sept 2012.

2.  Understand the role of every clinician in End of Life care  Introduction to symptom management at the end of life.  Awareness of the Gold standards Framework for the dying patient  Appreciate impact of DNAR  Practice Communication skills in end of life care

3.  What percentage of the population die every year?  A) 1%  B) 5%  C) 0.1%

4.  End of Life Care is important.  1% population die/year- mainly elderly non-cancer patients.  Too few people die at home or their place of choice.  Hospital admissions and deaths are expensive and may be preventable - care must be brought closer to home.  Everyone is involved in end of life care - most care is from the GP.

5.  The Long Walk Home….

6.  Your experiences  Think of a time when you have been involved: yourself, your family or friends…. Or caring for someone personally or professionally….  Write the story….

7.  Common themes?

8.  Tips/Frameworks which you’ve come across/use.

9.  SETTING  PERCEPTION  INVITATION  KNOWLEDGE  EMPATHY  STRATEGY AND SUMMARY

10.  Advance Preparation  Build a therapeutic envionment/relationship  Communicate well  Deal with the patient and family reactions  Encourage and validate emotions

11. Mr J L B Maketoni….

12.  Identification: we’re often the first person to suspect the severity of the illness  Informing and explaining: we are often the one who has to tell them or explain/translate or reinforce what “the hospital says”  Continuity and coordination: we are the patient’s advocate and involved at all stages with the patient and their family.

13.  The Gold Standards Framework is all about putting systems in place, taking a systematic approach to care.  There are seven C's, (key tasks)

14.  Communication  Coordination  Control of symptoms  Continuity and cross boundary working  Continued learning  Carer support  Care in dying phase

16.  The sensitivity of the surprise question "No" response was 75% and the specificity was 90%. Conclusions:  The surprise question is a simple, feasible, and effective tool to identify patients with the worst prognoses who should receive the highest priority for palliative care interventions, particularly advance care planning.

17. How do you feel about this being broached?

18.  Do Not Resuscitate (DNR) forms vs Allow Natural Death (AND) forms,  Many hospices have a policy that they do not carry out CPR and patients have to "opt in" rather than "opt out" of resuscitation  Ultimately it is the doctor's decision whether or not it is in the patient's best interests for a resuscitation attempt to be made - doctors do not have to provide anything they perceive to be a futile treatment.

19.  If relatives are offered "resuscitation" many will opt for this. However, if the success statistics, relative distress, morbidity and inpatient stays associated with CPR are discussed, many patients will not wish to undergo this intervention  paramedics will attempt CPR on a patient who undergoes cardiopulmonary arrest in an ambulance  Information to be recorded clearly in the notes

20.  Quiz in pairs/groups of 3.

21.  Pain  Nausea and vomiting  Intestinal obstruction  Breathlessness  Cough  Haemoptysis  Respiratory tract secretions  Spinal cord compression  Superior vena cava obstruction  Hypercalcaemia  Management of the last few days of life  Terminal restlessness and agitation  Use of steroids  Miscellaneous problems  Indications for the use of a syringe driver in palliative care

22.  15 min exercise  www.helpthehospices.org.uk/clip/pdf/hpp- 1.pdf www.helpthehospices.org.uk/clip/pdf/hpp- 1.pdf

23.  A worried wife.

24.  What are the barriers?  How do patients feel?  How do we feel?

25. Stages of bereavement: Denial Anger Bargaining Depression Acceptance Elisabeth Kubler-RossElisabeth Kubler-Ross.

26.  It is quite normal not to ‘feel’ anything following a death; people often have a delayed reaction.  Some people don’t deal with their emotions for days, months or even years after the death.  Many people feel angry about death they can feel guilty about being angry – it is normal to feel a sense of injustice.

27.  Understand the role of every clinician in End of Life care  Introduction to symptom management at the end of life.  Awareness of the Gold standards Framework for the dying patient  Appreciate impact of DNAR  Practice Communication skills in end of life care

28.  Questions?