Coordinating End-of-Life Care: The Importance of a Named Person

End-of-life care requires a coordinated approach to ensure that the physical, psychological, social, and spiritual needs of the patient are addressed. While decisions about a person’s care are made through multi-disciplinary discussions, there should be a named care coordinator of services. This lead professional could be anyone from a general practitioner to a specialist nurse, but their role is crucial in ensuring that best interest decisions are taken for people who lack capacity.

Early and ongoing conversations with the patient about planning their treatment and care are encouraged, and this communication should be informative, timely, and sensitive. Health professionals should support people in making choices about their preferred place of death, whether it be at home, in hospital, care home, or hospice. To support end-of-life care, practices should have a palliative care register that includes people with terminal conditions other than cancer, such as frailty, dementia, and heart failure.

Individualized care plans should be produced with the patient involved in the process, and the plan should be recognized in all care settings. Coordinating end-of-life care is essential to ensure that the patient’s needs are met, and having a named person to oversee this process is crucial.

Managing Thirst in a Dying Patient: Considerations and Options

As a patient approaches the end of life, their need for food and water decreases. However, thirst can still be a distressing symptom. When managing a dying patient’s hydration status, it is important to consider their wishes and preferences, as well as the potential risks and benefits of clinically assisted hydration. Here are some options to consider when a patient is complaining of thirst:

– Subcutaneous fluids: This can be a good option for providing symptomatic relief without overloading the patient with fluids.
– Increasing haloperidol in the syringe driver: While haloperidol can be helpful for managing nausea and vomiting, it is unlikely to improve thirst.
– Continuing mouth care and sips of water only: While this may be appropriate for some patients, it may not be enough to relieve thirst in others.
– Increasing morphine in the syringe driver: While morphine can be helpful for pain relief, it is unlikely to improve thirst.
– Inserting a nasogastric tube: If clinically assisted hydration is necessary, subcutaneous fluids are generally a more comfortable and less invasive option than a nasogastric tube.

Ultimately, the goal of managing thirst in a dying patient is to provide comfort and relief, rather than to prolong life. Each patient’s situation should be evaluated on an individual basis, with their wishes and preferences taken into account.

Divide the dosage of tramadol by 10 to obtain the equivalent dosage of morphine.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.

Treatment for Symptoms of Raised Intracranial Pressure in Brain Metastases Patients

This patient is experiencing symptoms of raised intracranial pressure due to brain metastases. Depending on the treatment aims and ceiling of treatment, radiotherapy may be indicated. However, pharmacotherapy can also aid in palliating symptoms. High dose corticosteroids, such as dexamethasone at 16 mg daily for four to five days, followed by a reduced dose of 4-6 mg daily, can help alleviate headaches caused by raised intracranial pressure. Other options may be considered as adjuncts to treatment for pain, nausea, and agitation. Nevertheless, dexamethasone is the best option as it directly targets the underlying problem causing the symptoms in this case.

Hypercalcaemia in Palliative Care Patients

Hypercalcaemia is a common life-threatening metabolic disorder in cancer patients, particularly in those with myeloma and breast, renal, lung, and thyroid cancers. The severity of symptoms doesn’t always correlate with the degree of hypercalcaemia but often reflects the rapidity of onset. In palliative care patients, hypercalcaemia is a medical emergency that requires immediate attention.

Intravenous fluid replacement and intravenous bisphosphonates are the treatments of choice for hypercalcaemia in patients with a reasonable short-term prognosis who are willing to undergo treatment. It is important to note that hypercalcaemia can result from renal failure, so a urea level test may be useful. However, isolated acute kidney injury doesn’t explain the symptoms and may lead to a missed diagnosis.

A high serum alkaline phosphatase level is usually present in patients with bony metastases, but it would not be the most useful test in isolation. Although anaemia may be present in some patients, it doesn’t fit with the acute clinical symptoms, and a haemoglobin level test would not provide useful diagnostic information.

Thirst and polyuria may suggest diabetes, but the clinical history makes hypercalcaemia a more likely diagnosis. Therefore, it is crucial to consider hypercalcaemia as a potential cause of acute symptoms in palliative care patients.

Understanding the Five Stages of Grief: Insights from Dr. Elisabeth Kübler-Ross

Dr. Elisabeth Kübler-Ross is known for her pioneering work in supporting and counseling individuals experiencing personal trauma, grief, and grieving, particularly in relation to death and dying. Her ideas, particularly the five stages of grief model, have been widely used to help people cope with emotional upheavals resulting from various life events.

The first stage is denial, which involves a conscious or unconscious refusal to accept the reality of the situation. This can be a defense mechanism that some people use to cope with traumatic changes. However, denial can also hinder the healing process if it is not addressed.

The second stage is anger, which can manifest in different ways. People may direct their anger towards themselves or others, especially those close to them. It is important to understand that anger is a natural response to grief and to remain non-judgmental when dealing with someone who is upset.

The third stage is bargaining, which often involves attempting to make deals with a higher power or trying to negotiate a better outcome. However, this rarely provides a sustainable solution for grief.

The fourth stage is depression, which can include feelings of sadness, regret, fear, and uncertainty. It is a sign that the person is beginning to accept the reality of the situation.

The final stage is acceptance, which varies depending on the individual’s circumstances. It is an indication that the person has achieved some emotional detachment and objectivity. People who are dying may enter this stage long before their loved ones, and they must go through their own unique stages of grief.

While Kübler-Ross’s concepts were developed through extensive interviews with dying patients, some have criticized her one-size-fits-all approach as being too simplistic. Not everyone will experience all of these stages, and they may not occur in a specific order. Nonetheless, understanding these stages can provide valuable insights into the grieving process and help individuals cope with emotional upheavals resulting from various life events.

Death Certification in the UK

There are no legal definitions of death in the UK, but guidelines exist to verify it. According to the current guidance, a doctor or other qualified personnel should verify death, and nurse practitioners may verify but not certify it. After a patient has died, a doctor needs to complete a medical certificate of cause of death (MCCD). However, there is a list of circumstances in which a doctor should notify the Coroner before completing the MCCD.

When completing the MCCD, it is important to note that old age as 1a is only acceptable if the patient was at least 80 years old. Natural causes is not acceptable, and organ failure can only be used if the disease or condition that led to the organ failure is specified. Abbreviations should be avoided, except for HIV and AIDS.

Once the MCCD is completed, the family takes it to the local Registrar of Births, Deaths, and Marriages office to register the death. If the Registrar decides that the death doesn’t need reporting to the Coroner, he/she will issue a certificate for Burial or Cremation and a certificate of Registration of Death for Social Security purposes. Copies of the Death Register are also available upon request, which banks and insurance companies expect to see. If the family wants the burial to be outside of England, an Out of England Order is needed from the coroner.

Hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide can be used to treat respiratory secretions and bowel colic with syringe drivers.

When a patient in palliative care is unable to take oral medication due to various reasons such as nausea, dysphagia, intestinal obstruction, weakness or coma, a syringe driver should be considered. In the UK, there are two main types of syringe drivers: Graseby MS16A (blue) and Graseby MS26 (green). The delivery rate for the former is given in mm per hour, while the latter is given in mm per 24 hours.

Most drugs are compatible with water for injection, but for certain drugs such as granisetron, ketamine, ketorolac, octreotide, and ondansetron, sodium chloride 0.9% is recommended. Commonly used drugs for various symptoms include cyclizine, levomepromazine, haloperidol, metoclopramide for nausea and vomiting, hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide for respiratory secretions/bowel colic, midazolam, haloperidol, levomepromazine for agitation/restlessness, and diamorphine as the preferred opioid for pain.

When mixing drugs, diamorphine is compatible with most other drugs used, including dexamethasone, haloperidol, hyoscine butylbromide, hyoscine hydrobromide, levomepromazine, metoclopramide, and midazolam. However, cyclizine may precipitate with diamorphine when given at higher doses, and it is incompatible with a number of drugs such as clonidine, dexamethasone, hyoscine butylbromide (occasional), ketamine, ketorolac, metoclopramide, midazolam, octreotide, and sodium chloride 0.9%.

Managing Hypercalcemia in Palliative Care: Admission, Treatment, and Diet Recommendations

Hypercalcemia, a rise in serum calcium levels, can cause a range of symptoms including weakness, anorexia, nausea, and constipation. Severe cases can lead to delirium, seizures, and coma. While some patients may not experience symptoms, hypercalcemia can be an emergency in palliative care. In cases where treatment is not appropriate, fluid replacement and bisphosphonates can alleviate distressing symptoms. However, symptomatic or moderate to severe hypercalcemia requires immediate admission to a hospital or hospice for management with intravenous fluids and bisphosphonates. A low calcium diet is unnecessary, and good hydration is the first-line treatment for mild asymptomatic hypercalcemia. Thiazide diuretics should be avoided as they can exacerbate hypercalcemia, as can lack of mobility.

To convert this patient’s daily dose of oral morphine to a more tolerable route, the dose should be divided by two. The ratio of oral to parenterally administered morphine is 2:1, meaning that subcutaneous or intravenous doses are half that of the oral dose. However, it is important to note that there has been no change in the patient’s condition or nature of pain, so switching to a different class of pain relief would not be appropriate. Transdermal patches may not be suitable for this patient as they are typically used for those with stable levels of pain and should not be given to opioid-naïve patients. A subcutaneous dose of 60 mg/24 hours is equivalent to 120 mg of oral morphine and would be an appropriate option. It is important to address the patient’s difficulty in taking their pain relief as the cause of their pain, rather than an increase in their pain requirements.

Palliative care prescribing for pain is guided by NICE and SIGN guidelines. NICE recommends starting with regular oral modified-release or immediate-release morphine, with immediate-release morphine for breakthrough pain. Laxatives should be prescribed for all patients initiating strong opioids, and antiemetics should be offered if nausea persists. Drowsiness is usually transient, but if it persists, the dose should be adjusted. SIGN advises that the breakthrough dose of morphine is one-sixth the daily dose, and all patients receiving opioids should be prescribed a laxative. Opioids should be used with caution in patients with chronic kidney disease, and oxycodone is preferred to morphine in patients with mild-moderate renal impairment. Metastatic bone pain may respond to strong opioids, bisphosphonates, or radiotherapy, and all patients should be considered for referral to a clinical oncologist for further treatment. When increasing the dose of opioids, the next dose should be increased by 30-50%. Conversion factors between opioids are also provided. Opioid side-effects include nausea, drowsiness, and constipation, which are usually transient but may persist. Denosumab may be used to treat metastatic bone pain in addition to strong opioids, bisphosphonates, and radiotherapy.