care of the dying - in 45mins?

Care of the Dying - in 45mins?

How not to send them to sleep

The task…

• 50 third year students on second term clinical placement at acute trust

• 0815hrs start

• Predefined topics (curriculum)

Med school’s objectives

• Perception of death– Quality of life– Cure at all costs?

• Basics of palliative care– Key players– WHO definition & goals– Palliative care services

development– Concept of ‘total pain’

• Assessment for palliative care– Physical,

psychologic, social, spiritual

• Ethical issues in palliative care– Euthanasia– Resuscitation– Withholding fluids

Some Learning Theory

• Building blocks– Pre-requisite

knowledge - need to re-activate it

– Presenting new material

– Eliciting a change in practice/performance

My lecture outline

1. A comparison of modern and ancient societies’ views on death

2. A case scenario - what is it like to die in an acute trust

3. Facts on where people die and what they die from

4. Kübler-Ross - 5 stages of dying5. The Hospice Movement6. Definitions of Palliative Medicine

My lecture outline (cont.)

7. Pain control and Palliative care assessments

8. Dealing with the request for euthanasia as a communication skill

9. The ethics and law surrounding euthanasia, and key definitions

10.Ethical decision making at the end of life11.CPR12.Summary

Grab their attention at the start

• A provocatory question related to their med school interview

……that interview for medical schoolthat interview for medical school

Did you say…Did you say…““I want to care for I want to care for patients” or that “I want patients” or that “I want to look after people”?to look after people”?

……that interview for medical schoolthat interview for medical school

Did you Did you thinkthink……““I want to care for I want to care for dyingdying patients” or that “I want patients” or that “I want to look after people to look after people who who are dyingare dying”?”?

1. Modern and Ancient Societies’ views on Death & Dying

• 2-way discussion – Their innate attitudes- Hard for both old society and still hard for

contemporary society to discuss

• All views welcome - facilitates exploration of attitudes

2. The Case Scenario

• Storyboard: a student clerking of an elderly patient with an acute stroke – recall of clerking skills

• But what was it like for the patient: same storyboard from patient’s angle– Introduction of new stimulus material: clinical

management, discussions with relatives re: CPR, accidental injury in hospital requiring intensive care

• Death is the outcome• To follow-up patients they clerk. To appreciate

what dying in a hospital might be like

What Miss Smith sawWhat Miss Smith saw


We could control her BP, her cholesterol, and then if CT scan excludes a

haemorrhage we can start her on anticoagulation for her irregular pulse

3. Where patients die and what they die from

• 2 buzz groups (1min)– Descending order of

proportion on inpatients dying from cacner, circulatory problems, respiratory conditions & neurologic conditions

• Recall of basic epidemiology concepts and integration with mortality of common pathology

• 2nd buzz group– Draw with non-dominant

hand the scene they picture when they are on their deathbeds.

• Exploration of attitudes: The majority of patients do not wish to die in hospital

4. Kübler-Ross - 5 stages of dying

• To revise the stages of dying and visualise how they apply to a patient with terminal illness

• An MCQ (various orders of the stages as options) - coloured handout: self-assessment to aid recall of pre-requisite knowledge

Doctors caring for the dying – 1960sDoctors caring for the dying – 1960s

Dame Cicely Saunders Dame Cicely Saunders founded St. Christopher’s founded St. Christopher’s Hospice in LondonHospice in London

Established that morphine Established that morphine given to cancer patients given to cancer patients gave excellent control of gave excellent control of pain with pain with no risk of no risk of addiction whatsoeveraddiction whatsoever

Realised the importance Realised the importance of caring for the bereaved of caring for the bereaved family and being aware of family and being aware of the the psychosocial psychosocial context of the patientcontext of the patient

Doctors caring for the dying – 1960sDoctors caring for the dying – 1960s

American American Psychiatrist, Elisabeth Psychiatrist, Elisabeth KüblerKübler-Ross-Ross

““On Death & Dying” On Death & Dying” (5 stages of dying)(5 stages of dying)

Interviewed over Interviewed over 200pts who were 200pts who were terminally ill (handout terminally ill (handout shows how)shows how)July 8, 1926 - August 24, 2004

1960s - 1960s - KüblerKübler-Ross: Stages of dying -Ross: Stages of dying (on being told you have a terminal illness)(on being told you have a terminal illness)

Those bloody nurses, I never get any peace. There’s

no privacy when you’re stuck in

here

2nd STAGE

ANGER

Oh..yes, it is me

1960s - 1960s - KüblerKübler-Ross: Stages of dying -Ross: Stages of dying (on being told you have a terminal illness)(on being told you have a terminal illness)

Where the hell’s my

family when I need them?

2nd STAGE

ANGER

Oh..yes, it is me

She doesn’t realise how

painful it is for them to see her dying and angry at the same time

5. The hospice movement

• To appreciate the multi-disciplinary tearm approach to managing patients who are ill

The hospice movementThe hospice movement

DOCTORS

MACMILLAN NURSES

HOME CARE or HOSPICE AT HOME

DAY CARE

OUTPATIENT CLINICS e.g. for pain

HOSPITAL SUPPORTTEAMS

IN-PATIENT CARE

BEREAVEMENT SUPPORT

MARIE CURIE NURSE

PHYSIOs and OTs

PHARMACISTS

PSYCHOLOGISTS

ALTERNATIVE MEDICINETHERAPISTS

6. Definitions of Palliative Medicine

• To recall the GMC duties of a doctor and understand how they marry up with the philosophy of modern palliative medicine (WHO)

• 2-way discussion with flip-chart: recall GMC duties

• Presentation of stimulus material (philosophy)

• Discussion helps students learn (build) relevant attitudes on basis of principles they already know

What is modern Palliative care?What is modern Palliative care?

WHO definition – WHO definition – Palliative care…Palliative care… Affirms life and regards death as a normal processAffirms life and regards death as a normal process Neither hastens nor postpones deathNeither hastens nor postpones death Provides relief from pain and other distressing Provides relief from pain and other distressing

symptomssymptoms Integrates four major areas of a patient’s care: the Integrates four major areas of a patient’s care: the

psychologic, the physical, the social and the psychologic, the physical, the social and the spiritual spiritual

Offers a support system to help patients to live as Offers a support system to help patients to live as actively as possible until deathactively as possible until death

Offers a support system to help family cope during Offers a support system to help family cope during the patient’s illness and in their own bereavementthe patient’s illness and in their own bereavement

Respect the right of patients to be fully involved in decisions about their care

Keep your professional knowledge up to date

Not allow your personal beliefs to prejudice your patients’ care

Work with colleagues in ways that best serve patients’ interests

What is modern Palliative care?What is modern Palliative care? A necessary A necessary

response to response to modern medicine modern medicine which has which has prolonged the prolonged the “dying trajectory” “dying trajectory” for most diseasesfor most diseases

Oncologists work Oncologists work hard to improve hard to improve survival outcomes survival outcomes for most for most malignanciesmalignancies

GTN 1879GTN 1879 DIAMORPHINE 1898DIAMORPHINE 1898 METOCLOPRAMIDE 1944METOCLOPRAMIDE 1944 ASPIRIN 1899ASPIRIN 1899

HEPARIN medical student J HEPARIN medical student J McLean 1916McLean 1916

STREPTOKINASE late 80s, STREPTOKINASE late 80s, early 90searly 90s

BETA BLOCKERS 1994BETA BLOCKERS 1994 EXTERNAL DEFIBRILLATORS EXTERNAL DEFIBRILLATORS

from 90sfrom 90s ACE INHIBITORS 1993ACE INHIBITORS 1993 ANGIOTENSIN II RECEPTOR ANGIOTENSIN II RECEPTOR

ANTAGONISTS 2000ANTAGONISTS 2000 DIGOXIN over 200yrs old DIGOXIN over 200yrs old

MAINSTREAM USE FROM 1996MAINSTREAM USE FROM 1996 SPIRONOLACTONE from 1996SPIRONOLACTONE from 1996

7. Pain control and Palliative Care Assessments

• To provide students with a framework within which they can build their learning of palliative medicine– Separation of

domains of knowledge for clarity

• You will need to KNOW:- About DISEASES, & their

natural history- About DRUGS, & their safe use

• You will need to be SKILLED:- In communication- To perform practical procedures

• You will need to have ATTITUDES:- That focus on empathic and

holistic patient care

You will need to know the WHO You will need to know the WHO analgesic ladderanalgesic ladder

1Non opioid

2Weak opioid

+Non opioid

3

Strong opioid+

Non opioid

7. Pain control and Palliative Care Assessments

• Anna is a 45yo married mother of children aged 7 & 11. She was recently found to have spinal metastases from breast cancer. She comes to your pain clinic

• How knowledge is used in the management of a patient’s problem

• Brainstorm - key Qs or issues they wish to focus on– Helps students to

practically apply knowledge

Management of pain – “Management of pain – “total paintotal pain””

Anna is a 45yo Anna is a 45yo married mother married mother of children aged of children aged 7 & 11. She was 7 & 11. She was recently found to recently found to have spinal have spinal metastases from metastases from breast cancer. breast cancer. She comes to She comes to your pain clinicyour pain clinic

Can I recognize patterns of Can I recognize patterns of pain (visceral, bony, pain (visceral, bony, neuropathic, soft tissue, neuropathic, soft tissue, incident)incident)

What shall I check for on What shall I check for on examinationexamination

What are the best drug & What are the best drug & non-drug strategiesnon-drug strategies

What will she have tried What will she have tried alreadyalready

How will I reassure her How will I reassure her about starting morphineabout starting morphine

Who else can help meWho else can help me How can I give her hope How can I give her hope

and explain my and explain my management plan to the management plan to the familyfamily

8.&9. Euthanasia - definitions, communication skills and the law

• To recall the definition of euthanasia and its variants– Self-assessment MCQ - try to gain clarity between

active, passive, voluntary, assisted suicide

• To appreciate why patients ask for euthanasia– Recall of stages of dying (Brainstorm) to re-inforce

attitude that terminally ill patients are fearful of dying - link this with euthanasia


• To provide a checklist for approaching communication with a patient who requests euthanasia– (No time to practise this skill)

Get ready

Get the patient/relative

to talk first – ask open questions, use your

silence

Be empathic: sense what they might be

feeling/thinking. Respond accordingly, watch for cues,

respond with open questions

Share information in easy to understand language.

Don’t dominate

Let them know what to expect next

What has made them come to ask you for euthanasia

Try to understand the reason for the request. Is it a mark of

distress or a calculated choice?

Explain that you cannot perform euthanasia. Try to answer the

distress behind the request

Summarise the discussion. Let them know you will see them again after they’ve had more

time to think about what you’ve said


• To appreciate the on-going legal/moral debate on euthanasia– 2 way discussion: would

you permit assisted suicide in this case (both are paralysed)?

– Attitudes of others in the audience

– Legal differences

Active assisted suicide Active assisted suicide

Paralysed by MNDParalysed by MND Wanted a change Wanted a change

in the law to allow in the law to allow her husband to end her husband to end her life at a time of her life at a time of her choosingher choosing

Active assisted suicide = illegalActive assisted suicide = illegal

Paralysed by MNDParalysed by MND Wanted a change Wanted a change

in the law to allow in the law to allow her husband to end her husband to end her life at a time of her life at a time of her choosingher choosing

Court decided “no, Court decided “no, even though you even though you are competent to are competent to make this choice”make this choice”

The Law has taken all my rights away

Passive assisted suicidePassive assisted suicide Paralysed by spinal Paralysed by spinal

haemorrhage, but haemorrhage, but kept alive on a kept alive on a ventilatorventilator

Wanted doctors to Wanted doctors to stop keeping her alive stop keeping her alive on a ventilatoron a ventilator

Ms. B v NHS trust

Passive assisted suicide = legalPassive assisted suicide = legal Paralysed by spinal Paralysed by spinal

haemorrhage, but kept haemorrhage, but kept alive on a ventilatoralive on a ventilator

Wanted doctors to Wanted doctors to stop keeping her alive stop keeping her alive on a ventilatoron a ventilator

Court decided “you are Court decided “you are competent, and have competent, and have the right to refuse life-the right to refuse life-saving treatment. saving treatment. Therefore the doctors Therefore the doctors are acting unlawfully are acting unlawfully in keeping you alive”in keeping you alive”

Ms. B v NHS trust

Current UK law is contradictoryCurrent UK law is contradictory

End result (assisted suicide) is the same – why should the means to achieve this matter to the

courts?

10. Ethical decision making at the end of life

• To appreciate the 5 principles of medical ethics and to appreciate how they are applied when managing the terminally ill– Brainstorm: recall of principles– Link these principles to questions doctors

ask– A case example (real patient management

problem)

Principles of medical ethics as Principles of medical ethics as applied to the terminally illapplied to the terminally ill

Will this active clinical measure Will this active clinical measure (antibiotics, fluid) provide good quality of (antibiotics, fluid) provide good quality of life?life?

Can I be sure that this active clinical Can I be sure that this active clinical measure will not prolong suffering of my measure will not prolong suffering of my patient?patient?

Is this what the patient truly wants or what Is this what the patient truly wants or what I want (“treating” my own conscience)?I want (“treating” my own conscience)?

Is this the best use of limited resources?Is this the best use of limited resources? Am I acting within the law?Am I acting within the law?

Beneficence

Non-maleficence

Autonomy

Justice

Legality

Mrs Pierce, MS for 25 years, admitted with pneumonia. Unable to communicate, cannot protect her airway. You think she may be dying. Antibiotics? Drip? NG feeding? CPR?

Previously expressed views on such issues in the past? Any advance statement?

Is there another clinician or GP who knows her well and can inform us?

What do those close to the patient think that Mrs. Pierce’s views would be?

Is she dying because of her primary illness MS or could it be something else?

What is my intent with the intervention?

What is the likelihood that the intervention will be beneficial?

What maximum quality of life could we achieve for this lady? Is this acceptable?

What distress might these active interventions cause? Is this acceptable?

How will the benefits and adverse effects be assessed?

Will any of these interventions reduce suffering in the dying process?

Who is making the decisions?

Does the whole team agree?

Who will communicate this with the relatives?

11. CPR

• To know the odds of survival post inpatient cardiac arrest treated with CPR and to briefly understand how DNR decisions are made– 2 way discussion (if your gran…). Asked

what they think the odds of survival are. Discern true fact from attitude

12. Summary and questions

• Opportunity for questions (Clarification)

• Enhance retention– Respect patients’ wishes where possible– Understand how individuals approach

death and dying– Reminder of what knowledge and skills

students will need

Constructivism - a theory of learning

• Building blocks– Pre-requisite knowledge

- need to re-activate it– Presenting new material– Eliciting a change in

practice/performance

• Techniques– Discussions, self-

assessment, brainstorm, buzz grps (and many more)

Ask yourself: what is your conception of teaching?

• Imparting information to my students

• Structuring knowledge for my students

• Facilitating a student-teacher interaction

• Helping students to understand what I know

• Encouraging the intellectual development of my students

William Osler (1849-1919): It’s more important to know what sort of person this disease has, than what sort of disease this person has.

care of the dying - in 45mins?

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