1. CARE TOWARDS END OF LIFE Dr. Nadeesha de Fonseka Consultant Anaesthetist BH- Panadura

2. End of Life care Do any of your patients ever die? Then you need to think about end of life care.

3. END OF LIFE Likely to die within few hours, days or within the next 12 months.

4. AIM 1.Create awareness about this group of patients 2.How, and what type of care is needed 3.How to Support the patients as well as the relatives 4.Ethical and legal issues

5. MRS. A – 60 YRS Diagnosed pt with bladder CA with multiple bone secondaries. Presented with fever, cough and acute SOB and low BP.

6. Mr B – 80 YRS Diagnosed pt with Hypertension and CRF. Needs support in feeding,mobilising and other basic needs. Presented with reduced UOP, confusion and a Pressure sore on the Left hip.

7. MRS. C – 70 yrs Diagnosed patient with DM and LVF with frequent exacerbations. Independant with regard to feeding, mobilising inside house, and dressing up. Having lot of family support. Presented with acute severe SOB and chest pain.

8. Mr. D – 30 YRS Fit and well man, met with a RTA. Patient is in the ICU Day 10, on ventilatory support, diagnosed to be in a persistent vegetative state.

9. GROUP OF PATIENTS Advanced, Progressive, incurable diseases General frailty and co-existing conditions Sudden catastrophic events Persistent vegetative state (PSV) Extremely premature infants

11. Equalities and Human rights The same quality of care as other patients Treat with dignity, respect and compassion Respect privacy and right to confidentiality

12. DECISIONS ON CARE ARE DIFFICULT Clinically complex (Multiple acute and chronic conditions) Emotionally distressing (Doctor Patient, Relatives, Medical Team) Some may involve ethical dilemmas Uncertainties about legal issues

13. Resource constraints Lack of availability of ICU beds Balance the duties towards the wider population Provide the best service within the resources available. Prioritise patients based on clinical need and capacity to benefit.

14. MOST CHALLENGING DECISIONS Withdrawal of treatment (Not Care) Not starting a treatment if it prolongs life Ex. Antibiotics CPR Dialysis Mechanical ventilation Clinically assisted nutrition (availability of resources)

15. BEST FRAME WORK Doctor and Patient making the decision together. Capacity to decide at the time of presentation?

16. Adult With Capacity to Decide The Doctor and Patient make an assessment of the condition and make decision. Doctor -Specialist knowledge -Experience -Clinical judgement -Potential benefits and Risks of each option. -Patient should not be pressurized to accept. -Patient has right to refuse an option.

17. Adult With Capacity to Decide PATIENT Decision making capacity should be maximised. Able to understand, retain and make the decision weighing the information given and to express the decision.

18. Adult Lacking Capacity to Decide.Doctor makes the decision based on whether the treatment option will be of over-all benefit to the Patient – Advanced directives – Proxy – Previous wishes of patient.

19. COMMUNICATION WITH RELATIVES – Doctor should respect their views and feeling as well. – Terminology and wording should be used carefully, – Poor communication leads to legal issues. – 2 nd opinion if serious difference of opinion

20. PALLIATIVE CARE Objective Support the Patient to live as well as possible until they die Hydration Nutrition Management of distressing symptoms – Pain – Breathlessness – Agitation / Depression etc.

21. CPR / DNAR Benefits of Prolonging LifeRisks and burdens of Rx

22. CPR / DNAR (Contd.) Not only a clinical decision Quality of life Family support Patient’s wishes If resuscitated – Is multi organ support in an ICU appropriate ?

23. COMPLICATIONS OF CPR Interventions are invasive – Forceful chest compressions - fractures – Electric shock – Injecting Drugs – Ventilation + Intubation Hypoxic brain damage Survive with disability If unsuccessful patient dies in a traumatic undignified manner.

24. What does a good death look like? Calm, controlled, pain free, at peace with self and important others Sudden but timely

25. Allow Natural Death This will ensure last hours or days are spent in their preferred place of care with the preferred people. Patient dies in a peaceful and dignified manner.

26. Thank you. How people die remains in the memory of who live on.