1. ST1&2 PALLIATIVE CARE & ETHICS Niall Cameron Rosalie Dunn Elayne Harris Euan Paterson

2. Palliative Care and Ethics 09:00 Diagnosing dying / Anticipatory Care Planning 10:30End of Life Ethics 11:45Coffee / Tea 12:00Symptom Relief in Palliative Care 12:45 Dining with death! 13:30 Do Not Attempt Cardio-Pulmonary Resuscitation – key issues & approach 14:45Coffee / Tea 15:00The ‘Good Death’ 16:30Feedback / Close

3. Some all too common problems… The ‘sudden’ deterioration What does the patient know / think / want? What do the family know / think / want? Lack of medication Blue light ‘999’ at end of life Who knows what? The weekend catastrophe The ‘bad’ death… …and then 4 hours to confirm it happened!

4. Anticipatory Care Planning (ACP) What is it? Why is it (possibly) more important in palliative care? Which patients is it for?

5. ‘Marla doesn’t have testicular cancer. Marla doesn’t have Tb. She isn’t dying. Okay in that brainy brain-food philosophy way, we’re all dying, but Marla isn’t dying the way Chloe is dying’ Chuck Palahniuk - Fight Club

6. Death High Low Many years Function Death High Low Months or years Function Organ failure 6 Acute 2 Dementia, frailty and decline 7 Death High Low Weeks to years Function 5 Cancer GP has 20 deaths per list of 2000 patients per year Numbers and Trajectories

7. Diagnosing dying What primary disease do they suffer from? How are they at this moment? How rapidly are they changing? Would you be surprised…?

8. Which patients is it for? Patients with supportive / palliative care needs – Whoever YOU feel should be included! – Palliative care register – GSF register – SPICT / GSFS prognostication guidance? – Chronic disease registers? – Care Home patients?? – Housebound patients???

10. Anticipatory Care Planning (ACP) What is it? Why is it (possibly) more important in palliative care? Which patients is it for? What does it entail?

11. Legal Personal Medical Potential Problems Liverpool Care Pathway ePCS / KIS Welfare Power of Attorney Advance StatementThinking ahead & making plans Anticipatory Care Planning Just in Case DNA CPR SPAR DN Verification of Death GSFS Advance Care Planning Continuing Power of Attorney 1 Statement of values 2 Preferences & priorities 3 Advance decision to refuse treatment 4 Who else to consult Guardianship Anticipatory Care Planning SPAR Lanarkshire Home Care Pack

12. Legal Capacity – Welfare Power of Attorney – Continuing Power of Attorney – Guardianship Consent (ePCS / KIS) – To record – To transfer Advance decision to refuse treatment

13. Clinical Consideration of potential problems -What is likely to happen to THIS patient -What might happen to THIS patient DNACPR Just in Case -Proactive prescribing DN Verification of Expected Death Liverpool Care Pathway for the Dying Bereavement

14. Patient / Personal Preferred priorities of care – Place of care – Place of death – Admission? – Aggressiveness of treatment What is wanted What is not wanted – Who is to be involved

15. The views and wishes of patient / carer ‘My thinking ahead and making plans’ -What’s important to me just now -Planning ahead -Looking after me well -My concerns -Other important things -Things I want to know more about e.g. CPR -Keeping track Developed from work by Professor Scott Murray & Dr Kirsty Boyd, University of Edinburgh

16. Advance statement Statement of values -E.g. what makes life worth living What patient wishes -E.g. place of care, aggressiveness of treatment What patient does not want -E.g. PEG feeding, SC fluids, CPR Who they would wish consulted

17. Anticipatory Care Planning (ACP) What is it? Why is it (possibly) more important in palliative care? Which patients is it for? What does it entail? What is the process? – When should this be done? – Who should do it? – How should it be done? – How should it be shared?

18. ACP Process When should this be done? – At any time in life that seems appropriate – Continuously Who should do it? – By anyone with an appropriate relationship! How should it be done? – My Thinking Ahead & Making Plans – Carefully – Write it down How can it be shared? – ePCS / KIS – Other communication

19. Which patients is ePCS / KIS for? Patients with supportive / palliative care needs – Whoever YOU feel should be included! – Palliative care register – GSF register – SPICT / GSFS prognostication guidance? – Chronic disease registers? – Care Home patients?? – Housebound patients???

20. What is ePCS / KIS for? Information transfer – ‘In Hours’ GP > OOH – Primary Care > A&E / Acute Receiving Units – Primary Care > Scottish Ambulance Service Prompts for proactive care Anticipatory Care Planning All data stored in one place Structure for lists / meetings / etc Palliative care DES

21. What does ePCS / KIS contain? Information upload – Palliative Care review date – Consent to share information Current situation – Diagnoses – Key personnel involved – Carer details – Current treatment Repeat Last 30 days Acute – Patient & carer understanding Diagnosis & Prognosis

22. What does ePCS / KIS contain? Future Care Plan – Patient wishes (VISION) – Preferred Place of Care – Resuscitation status – Additional drugs in house (Just in Case) – Advice for OOH GP e.g. Contact own GP OOH GP willingness to sign death certificate – Additional OOH information (KEY section) e.g. Patient wishes Starting Liverpool Care Pathway Etc…

23. The ACP Checklist Capacity – Power of Attorney / Possible future problems? Have we considered – What is likely & what might happen to this patient? – Where the patient would like to be cared for? – CPR / DNACPR? – OOH information transfer (ePCS / KIS) Have we considered the possible need for – Anticipatory prescribing (Just in Case) – RN Verification of Expected Death – The Liverpool Care Pathway for the Dying The patient / carer view – My Thinking Ahead & Making Plans…