Author: Laura Tucker, Ollie Minton / Editor: Charlotte Davies / Questions: Sarah Edwards / Codes: / Published: 31/07/2018

A patient attends majors, with sepsis. You overhear someone saying “they’re palliative care, so we don’t need to do anything.” You know they’re wrong. There’s more to palliative care than letting people die… Read on to find more!

What is Palliative care?

It might sound obvious but many people don’t really know. Palliative care refers to a change in focus of care towards supportive comfort measures and dignity. It’s about a new goal of care and making it as individualised as possible.

This doesn’t mean that the patient is imminently dying. If your patient is dying, it’s important to diagnose this like any other diagnosis. Not that the patient is palliative or End of Life, these are just euphemisms and we need to avoid them when we’re talking about a patient in their final days or weeks of life. If you do expect your patient to die in the next 12 months, then #havetheconversation. There’s further resources on this on our podcast, and blog, with external links signposted here.

This doesn’t mean that we should stop treating problems. It’s about individualised care so mending the fractured neck of femur or treating the spinal cord compression might give a hospice patient an extra month or two comfortably talking with their family.

Sadly, a peaceful death is something you have to opt-in to in UK today. Everyone – patients, families & professionals – needs to #HaveTheConversation & get the protection of a DNACPR form in place if CPR would be unwanted, futile or inappropriate. #IWantAPeacefulDeath

— COTE Bangor (@COTEBangor) February 16, 2018

Which patients should / could be referred to palliative care

If unsure, pick up the phone and speak to the team. As perhaps expected, they are the nicest people in the hospital and always willing to give advice.

In general, refer patients with symptom management requirements who are likely in the end stage of their disease process, whether their disease is cancer or a non-malignant disease like heart failure. In addition to this, the palliative care team will help support patients and their important people (not always just their family) psychologically with the prospect of deteriorating health and death. They can also help with discharge planning and referral to hospice

Remember, it isn’t just oncology patients that would benefit from palliative care!

Another #sketchnote in the series based on the Prognostic Indicator Guidance: Heart Disease. Checkout the COPD one too! #EOLC #hpm #FOAMED #FOAMeol #FOANed #pallcare @hospicedoctor @WeEOLC @AusNurseEd @palliverse @fionaDmurphy @DyingMatters

— EOL Professionals (@eolpros) February 25, 2018

Which patients should / could be referred to a hospice

Every hospice has their own individual criteria, and your local hospital palliative care team will be able to assist. Broadly speaking, hospices will accept patients with:

Complex symptom management needs e.g. Uncontrolled pain.

A prognosis of likely days to short weeks, where they would go to die.

If your patient is not suitable for hospice admission, refer to the community palliative care team and they can support your patient with symptoms/ psychological needs in their home or nursing home.

“The Bread and Butter of Palliative Care”

Always think of the key symptoms that we ask about for every patient to ensure they are comfortable. Even if your patient isn’t palliative, you’d do well to remember these key symptoms!

PAIN Don’t be afraid to give high doses of opioids if your patient is already taking them and give an appropriate PRN dose (ie. a sixth of the total daily dose, remembering to convert even your weak opiates – codeine is about 6mg of morphine equivalent).

BREATHLESSNESS Again, don’t be afraid to give opioids. Don’t forget to check the renal function and prescribe oxycodone if eGFR <30

NAUSEA and VOMITING. Think why? And don’t prescribe ondansetron. It will only worsen the constipation.

SECRETIONS glycopyrronium is a good choice, but hyoscine can also be used.

AGITATION check if there’s an underlying cause. A bit like thinking about delirium causes: are they constipated, do they have an infection. Midazolam is there too as a treatment option.

In a patient who is dying, ensure that all these symptoms are addressed and prescribe subcutaneously on the PRN side. Your hospital will have guidelines. There are also guidelines online.

Treatment Escalation Plans

Even if you only have a short time with a patient, start getting into the habit of wondering “what should the treatment escalation plan be?” Involve your patient and their important people in this decision and don’t be afraid to have the difficult conversations early. It’ll save the patient unnecessary distress later on when millions of people are stabbing them with needles and getting flustered around them at 3am.

In ED, you are not expected to definitively decide whether your patient is not for MET calls or ward-based care. But you need to have started these discussions. and think about whether they are at risk of deteriorating and documented it clearly in the notes. It will help guide the team into the most appropriate focus of care.

Always check whether your patient already has a treatment escalation plan from the community. Don’t forget: the DNAR form is only a small part of the escalation of treatment.

This is all summarised wonderfully here.

#HaveTheConversation “we will offer you all the treatments that will work but avoid ones that won’t”

— Alexandra Danecki (@AlexDanecki) February 12, 2018