Embedded Files
FM&PH – Palliative care
In module Family Medicine and Public Health
This case follows Mr Field after his diagnosis with advanced prostate cancer and considers the role of the GP and other health care professionals as he progresses towards the end of life.
MAIN CASE
Guidance and Resources – Palliative care
Case Introduction – Palliative care
Further Case Information – Palliative care
Background Science – Palliative care
Case Conclusion – Palliative care
Formative Assessment – Palliative care
CASE COMPONENT
Guidance and Resources – Palliative care
In case FM&PH – Palliative care
Recommended Essential References
Here is a list of useful links for further information. You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
· Palliative care services in ministry of national guard
· The NHS choices website is helpful in outlining end of life care. This is a patient facing website.
Additinal Reading/Resources
· The GMC document, Good Medical Practice (2013), also provides guidance to doctors about treatment and care of patients who require end of life care.
CASE COMPONENT
Case Introduction – Palliative care
In case FM&PH – Palliative care
Dr Strong started working in a GP surgery in Rochdale four weeks ago. On his first day, he is asked to do a home visit to Marlon Field. He takes a look at the medical history on the practice records and notes that Mr Field recently joined the list. He is a 72-year-old gentleman diagnosed with advanced prostate cancer and bony metastases. He has completed numerous courses of treatment but has been told by his consultant that no further treatment is planned. The diagnosis has been discussed with him and he accepts that little else can be done.
His past medial history includes coronary heart disease, COPD and a previous CVA. He is on multiple medications orally and inhaled as well as NSAIDs and Fentanyl patches for pain control. He lives with his elderly wife in a two-storey terrace house and his extended family live nearby. He is a retired baker.
His family have requested the home visit as he is generally unwell and is complaining about worsening aches and pains in his back and legs. He was seen by another GP colleague last week and was put on a ‘50’ fentanyl patch (equivalent to 120mg dose of morphine in 24 hours) with oramorph 10mg/5ml. They advised they can take oramorph 7.5mls (15mg) up to four times a day.
When Dr Strong visits, he notes that Mr Field is frail and in considerable discomfort when moving. There is little else to find on examination. Mr Field is currently using oramorph at the maximum dose as well as the fentanyl patch. This suggests the fentanyl patch is not sufficiently alleviating the pain. He is concerned about Mr Field’s pain relief but isn’t sure whether to change or increase it.
· The BNF: there is excellent advice on prescribing for the types of symptoms patients might experience that you might not have thought about before as well as changing doses of opiates. Take a few minutes to familiarise yourself with the “Prescribing in palliative care’ chapter.
Who else could advise you about this?
Support will vary depending on the location, but there will usually be help available from a Macmillan team or the local hospice. They both are experts in symptoms control in end of life care.
Dr Strong decides to increase his fentanyl to a ‘75’ patch, which is equivalent to 180 mg daily of morphine. He can continue to utilise Oramorph for break through pain.
What is the dose of oramorph he can now take?
Also note that: Oramorph comes as 10mg/5ml of morphine. The 75mcg fentanyl patch is equivalent to 180mg daily of morphine.
Breakthrough calculation should be between 1/10 and 1/6 of 24 hour morphine. Therefore each break through dose should be between 18 and 30mg morphine (9-15ml of Oramorph)
The palliative care team asks whether he has any other symptoms such as pruritus or insomnia.
Drag and drop the appropriate medication that could be used to treat the following symptoms.
Later the practice manager reminds Dr Strong that the Palliative Care meeting is scheduled for the next day.
The Royal College of General Practice has produced some useful guidance that you should review prior to considering these questions
Which of the following people should be invited to a multidisciplinary team (MDT) palliative care meeting?
· Reception manager
· The patient
· The GP
· Macmillian or specialist cancer nurse
· District nurse
· Chairperson of the patient participation group
· Reception manager
.Correct answer.
· The patient
· The GP
.Correct answer.
· Macmillian or specialist cancer nurse
.Correct answer.
· District nurse
.Correct answer.
· Chairperson of the patient participation group
Considering your response to the previous questions: why do you think these particular people might attend the meeting? Try and formulate your reply before expanding the answer.
There are no hard and fast rules but ideally all clinical staff should attend who are involved or may become involved in the patients’ care. It may also be appropriate to invite members of the administrative team so that everyone is aware of patients who may need additional support. Remember all member of the practice team are bound by confidentiality agreements. Generally patients or their representatives wouldn’t attend these meetings as they tend to be an ‘overview discussion’ of all the patients at the practice, however the same MDT will meet with the patient and their family to discuss their care in more detail.
What might be discussed and why at these meetings? Try and formulate your reply before expanding the answer.
These meetings allow the multidisciplinary team to think ahead about how to provide high quality care in accordance with the patient’s wishes. The Gold standards framework suggests three steps: IDENTIFY, ASSESS and PLAN care according to the needs of the patient and carer. GP practices are required by the quality and outcomes framework (QOF) to hold meeting quarterly however more frequent meetings/ discussions are good practice. In addition to planning ahead, good communication between the team is important in ensuring safe handover of patient care.
Which types of patients can be discussed? Try and formulate your reply before expanding the answer.
It’s a common misconception that palliative care refers only to patients with cancer. Any patient approaching end of life can and should be discussed. A useful question to as is: “Would I be surprised if this patient died in the next 6-12 months?” If the answer is no then consider adding this patient to the palliative care register. Around 1% of a practice population die each year and about 25% of patients die from cancer and 75% from non cancer related causes.
Further Case Information – Palliative care
In case FM&PH – Palliative care
Dr Strong visits Mr Field a week later. His pain is better on this new regime. However, he is scarcely eating and struggling to get out of bed, even to the toilet due to feeling weak. He asks the GP if he is dying and how long he has got. His wife looks anxious and doesn’t seem to want Dr Strong to discuss this with him.
Reflect upon what Dr Strong should do in this situation: should Dr Strong discuss his prognosis despite his wife’s reservations?
NOTE: If you want to save your reflections for later, please use ‘My notes’ box at the bottom of the page which will save within ‘my notes’ tab at the top of the page.
When considering this question it’s suggested that you revisit the basic principles of ethical decision making, these would include: autonomy (respect for the patient’s right to self-determination encompassing confidentiality), beneficence (the duty to ‘do good’), non-maleficence (the duty to ‘not do bad’) and in this case, justice (respect for the patients rights).
Some issues you should consider
What potential discussions could have taken place already to make this situation easier for everyone? Should you have already established Mr Fields ‘wishes’ and if so when would have been the right time to do this? Talking about this when a terminal diagnosis has been made and establishing both the patient and families expectations is important. It may help to ask the patient what they want to know and how much detail they feel comfortable with.
Does the patient have capacity? If Mr Field is able to make decisions does his right to know about his condition supersede his family’s wishes? What might be the implications if you chose not to listen to his wife? How might this affect your future relationship and how might your protect this?
What might be the implications if you chose not to inform Mr Field that he was approaching the end of life? Would you be colluding with his wife? What might this prevent Mr Field from doing? Not informing Mr Field might be denying him the chance to talk to his family and friends and set his affairs in order.
The following week, Dr Strong is asked to call Mrs Field back. She is really upset as Mr Field was seen by the out of hours (OOH) doctor, who diagnosed a chest infection. As Mr Field was so unwell, Dr Strong wanted to send him to the hospital. However, Mr Field and his family wanted him to stay at home, and Mr Field refused admission. Dr Strong therefore arranges to visit Mr Field at lunchtime.
Consider your response to the following questions before expanding the answers.
Bearing this in mind, what discussion should Dr Strong now be thinking of having with Mr Field and his family? What is it important to determine and communicate at this stage in his care?
Clearly some thought should have been given towards the ceiling of care that is appropriate for this patient and this needs to be communicated to everyone who is involved in looking after him, including the out of hour providers. It would be prudent to have these discussions with the patient and his family before he deteriorates so that those involved are not forced into making a difficult decision such as declining an admission to hospital.
Consider what information an out of hours handover form might contain?
1. Patient demographics and contact details of carers and usual GP
2. The main diagnosis and other relevant issues
3. Known allergies and drug reactions
4. Current medication and additional drugs available at home including whether a syringe driver is available
5. Patient and carer’s Understanding of diagnosis and prognosis
6. Any special advice that out-of-hours care need to be aware of
7. What care plan has been agreed?
8. Preferred place of care: this might include that the patient does not want to be admitted to hospital
9. Whether the usual GP can be contacted out of hours?
10. Resuscitation status agreed? (if yes, status)
11. Will the usual GP be able to sign a death certificate?
Ideally these forms should be updated regularly and especially if there has been any change in circumstances to ensure everyone involved is fully informed, that the patients decisions are respected and that care can be delivered safely. It’s unlikely that the OOH team will have access to a full set of medical records so to be able to treat Mr Field safely they need clear and up to date information about his current condition including the medication prescribed.
IN PRACTICE: Ask your GP tutor what system they use to update the Out of Hours (OOH) services. Many GPs have a web-based tool – if possible ask your GP to see what information is included on this system.
Considering a Do Not Attempt Resuscitation (DNAR) form
Part of this planning should also include difficult decisions around whether resuscitation should be attempted.
A DNAR form should be remain with the patient at all times
True
False
True
Rather that stay at home filed away the form should remain with the patient.
Forms should be considered indefinite unless the patient revokes the decision, a fixed review date is not recommended but it may be appropriate to review the decisions as clinical circumstances change.
True
False
False
Forms should be considered indefinite unless the patient revokes the decision, a fixed review date is not recommended but it may be appropriate to review the decisions as clinical circumstances change.
You can view some example forms at Resuscitation Council UK
Some commentators are now questioning whether the phrase ‘allow natural death’ might be a more appropriate term to use. There is some evidence supporting the premise that ‘allow natural death’ may be more acceptable to patients and their families.
Next week the district nursing sister suggests a joint visit with the GP to see Mr Field.
He is now extremely frail and his family report that he is increasingly drowsy but on occasions has been agitated and confused and his breathing sounds rattly. His pain relief was further increased by another GP colleague last Thursday, which was not Dr Strong’s clinical day. He seems comfortable and not in any pain.
He is now really struggling to swallow his regular medication: aspirin, isosorbide mononitrate, simvastatin and bisoprolol and wants to know if it’s ‘worth’ taking it.
His wife is worried that he’ll have an angina attack if he doesn’t take it.
What should Dr Strong advise to do about his regular non-palliative medication?
This is a common but difficult scenario. There certainly needs to be an open and honest discussion with Mr Field and his wife about the goals of his care at present, these discussions should be revisited regularly. Once again it’s worth revisiting the ethical framework we discussed above.
Some questions to consider:
· Is Mr Field able to make this decision himself and should we respect his decision even if we don’t agree with it?
· What effects are these medications having now? Are they realistically prolonging his life at present?
· Much of the evidence supporting medications such as statins relates to their long-term effect, how much difference will they make to the last few weeks of someone’s life?
· Could his medications be causing him harm? As someone reaches the end of life they may have lost weight or become dehydrated as a result the medication may result in increased morbidity e.g. hypotension.
· Could stopping the medication result in psychological harm? You may worry that the Mr Field and his family might view stopping his medication as ‘the final step’ in his care.
Picture191.jpgAs Dr Strong leaves, the district nurse asks him if he would like her to bring a syringe driver to the home. If so, she asks him if he would prescribe any drugs and fill in paperwork for the integrated care pathway. Dr Strong is a little taken aback; he didn’t think Mr Field was ill enough to start medication via a syringe driver.
Consider your response before expanding the answers.
Why might the district nurse have made this suggestion now?
Once again it is worth revisiting the suggestions from the gold standard framework, preparation is key in planning for the best care. Although the medications may not be required today having them available in the house means the family and other healthcare professionals wouldn’t have to try and obtain them when the time arises. This is especially important for out of hours care when pharmacies may be closed.
What drugs might the GP prescribe?
You should at this point read the chapter on prescribing analgesia in Prescribing Skills Handbook 2 and the Chapter in Prescribing Skills Handbook 1 Chapter 3 re: formulations and administration of medicines.
It would also be useful to return to the palliative care section of the BNF again. Think about the symptoms that Mr Field has been experiencing and select the correct drug.
Pain
· Diamorphine
· Dihydrocodeine
· Diclofenac
Diamorphine
.Correct answer.
Restlessness and Agitation
· Temazepam
· Midazolam
· Diazepam
Midazolam
Nausea
· Cyclizine
· Ranitidine
· Esomeprazole
Cyclizine
IN PRACTICE: Ask your GP Tutor if you can visit with them or another GP in the practice, somebody who is at the end of life (if appropriate). Alternatively, or additionally, you could find out if it would be possible for you to attend a Palliative Care meeting, where there might be other members of the multi-disciplinary team (MDT) present, who you might be able to speak to and find out about their role e.g. District Nurses, Macmillan nurses.
You can also compare and contrast your experiences in the community with those in hospital when you do/have done your other speciality blocks, including Ageing and Complex Health.
CASE COMPONENT
Background Science – Palliative care
In case FM&PH – Palliative care
Planning ahead isn’t just for the medical team. Patients and their families also need to think about what is best for them. NHS Choices offers some practical advice and a good summary of the issues raised in this case.
Case Conclusion – Palliative care
This makes him comfortable and his family are relieved. The following night he dies peacefully in his bed. The OOH doctor visits and confirms death. His family are confused with what happens next.
Although the rules may seem complex there is very clear guidance, read through the following documents which will enable you to answer the following questions
GOV.UK: What to do after someone dies
Dr Strong is able to issue the medical certificate of cause of death
True
False
True: he has attended the deceased in the 2 weeks prior to death and is able to provide a cause of death
The coroner must be informed
True
False
False: provided the GP is satisfied what the cause of death was, according to the guidance above there is no need to inform the coroner
The family must take the death certificate to register the death within 24 hours.
True
False
False: Although the family must provide the medical certificate of cause of death to register the death, he have 5 days to do so within the U
Formative Assessment – Palliative care
Dr Strong has started working at the local hospice on Thursdays. This week is particularly busy, and he finds that there are many tasks to deal with during the morning ward round.
Mrs Hassan has metastatic breast cancer and is now unable to take oral medication. The matron advises Dr Strong to convert her MST dose of 60 mg twice a day to an equivalent dose of a Fentanyl patch.
What is the correct dosage? Use the drug conversion drug in the prescribing in palliative care section in the BNF to help you convert to an equivalent dose of a fentanyl patch, changed every 72 hours. (https://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/prescribing-in-palliative-care/pain/pain-management-with-opioids)
· Fentanyl 25 mcg
· Fentanyl 50 mcg
· Fentanyl 75 mcg
· Fentanyl 100 mcg
· Fentanyl 50 mcg
.Correct answer.
Increasing the dose wouldn’t be appropriate at this point as there is no mention of any deterioration in his pain control. See https://www.evidence.nhs.uk/formulary/bnf/current/guidance-on-prescribing/prescribing-in-palliative-care/pain/pain-management-with-opioids for further information.
Mr Kowalski has developed noisy rattly breathing. He isn’t agitated. Which of the following medications might be used in a syringe driver to help?
· Glycopyrronium Bromide
· Midazolam
· Buprenorphine
· Amitriptyline
· Glycopyrronium Bromide
.Correct answer.
Glycopyrronium Bromide is the correct answer. Although Amitriptyline may result in a dry mouth it isn’t suitable to reduce respiratory secretions. Buprenorphine is prescribed for pain relief and usually via a patch. Midazolam is used to reduce agitation.
Miss Farmer died during the night. Dr Strong has not seen her since her last shift one week ago. He is unsure whether he can issue a death certificate. Providing the cause of death is certain, how soon prior to death must a doctor see a patient to be able to issue a medical certificate of the cause of death?
· 1 day
· 1 week
· 2 weeks
· 4 weeks
· 2 weeks
.Correct answer.
In this situation it’s likely that Dr Strong will be able to give a cause of death in section 1a. To issue the certificate the doctor must have seen the patient within 2 weeks.
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