September MCLGsessionLast phase of life

Introduction ( 10 minutes)

Welcome and Introductions especially to Visitors who can give the group a brief on their role and priorities for the session from their perspective

Learning objectives

By the end of the session you should be ableto :

1. Identify and share challenges faced in the last phase of life and develop ways to approach these.

2.Further your understanding of how the different services can work together to provide person centred co-ordinated care.

3. Share resources, a tool kit and develop useful contacts to access expertise and support.

SLIDE 2 Scale of the problem - to share and discuss with the group the graphs for reflection

SLIDE 3 Old Concept and New Concept - to share and discuss with the group the graphs for reflection.

Case study

SLIDE 4

Part 1 30 minutes ( small group)

Mr Stoical is 88 and lives with his wife in a ground floor maisonette. For many years he has cared for his chronically ill wife who had old TB, has severe COPDand she is now thin, frail and housebound. She has recently developed some early memory loss. The couple have 3 adult children- 2 live locally and one lives abroad.

Mr Stoical was diagnosed with a slowly progressive leukaemia 10 years ago. He has also had a bypass for coronary artery disease, was stable for many years but then developed symptoms of stable angina and heart failure. He is followed up by the haematologists and by the cardiologists. He now has end stage kidney disease, attends the kidney clinic and is followed up for this by his GP.The cardiologists and kidney physicians feel that he is on the maximum tolerated drug treatment, but he is increasingly short of breath on walking and can no longer walk to the post-box just outside his house without stopping several times to catch breath. He sleeps propped up with 3 pillows at night.

SLIDES 5-8

  1. Which of these three disease trajectories would you expect for Mr Stoical? And for his wife? What are the roles of different members of the MDT (clinical and non clinical)? Is there a clear team leader, and how is this decided and communicated?
  2. In your role what symptoms and signs might you, the patient or the carer observe if they deteriorate? What can make it difficult to recognise deterioration? How do we recognise our gaps in knowledge and what resources can we access to help us with these difficult decisions? (Consider Slide 9 at the end of discussion to summarise.)
  3. What reversible causes do you need to exclude if they deteriorate?Who could advise you? Facilitator note: invite experts to contribute and participants to share their uncertainties.

Examples of potentially reversible causes of deterioration:

Low Haemoglobin level/ Anaemia, Bleeding due to low platelets, Infection,

Dehydration leading to confusion and delirium, Hypercalcaemia, Malignant Spinal Cord Compression, Pulmonary Oedema, Myocardial Infarction/ Heart Attack, Type 2 Respiratory Failure with hypercapnia (CO2 retention), Opioid toxicity, Renal failure,

Biochemical abnormalities

Part 2 ( small groups)30 minutes

Mr Stoical has been feeling increasingly tired. He has an appointment with his haematologist who tells him that his leukemia has deteriorated. After his last chemotherapy treatment 18 months previously he had already decided that he would refuse further chemotherapy. At his appointment, he tells the haematologist his decision. His haematologist thinks that on balance, that this is a reasonable decision. He offers him a blood transfusion for some palliation of symptoms but Mr Stoical declines this too. His daughter is furious with his decision.

The following week;

a) The duty GP has been asked to review Mr Stoical because he is getting breathless.

b) The pharmacist is delivering the dosette box and noticed there was no prescription issue for the statin.

c) The district nurse has received a referral from the haematology nurse for a continence assessment . She has no other information.

d) The social worker has been asked to do an assessment for personal care and benefits, by the daughter.

e) The receptionist has received a worried phone from Mr Stoical about his medicines.

When you visit in one of the roles above, his daughter and wife are present. Mr Stoical looks thin, pale and tired. He is now short of breath when he walks to the door of his room. He explains his decision with everyone present and asks you how long you think he has left to live. His wife looks worried.

  1. If you had visited, in your role how would you respond to Mr Stoical and the family? (including family, cultural and religious beliefs.) Are there sources of ethical, cultural or religious guidance that could help with difficult decisions e.g prolongation of life)
  2. How would you assess Mr Stoical’s prognosis? Who else could help you with this? (General prognostication tools and Disease specific tools slide 10).Look at the SPICT tool and discuss Mr Stoical or a patient you are currently uncertain about. SLIDE 12-13Resource pack - SPICT Tool and Table 2 Reference pg 333 Table 2. Clinical indicators of disease progression.
  3. What would you do next?

Plenary (15mins)

  1. How can we improve on what we currently do and how might we do this?( involve other members of the team, co-ordinating care, care plans- see appendix 1 practical guide for preparing for death in the community ( appendix 1 of the lesson planning guide)

Evaluation (5mins)