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CARE TOWARDS END OF LIFE

CARE TOWARDS END OF LIFE. Dr. Tharanga Perera Consultant Anaesthetist BH- Wathupitiwela. END OF LIFE Likely to die within few hours, days or within the next 12 months. MRS. A – 60 YRS.

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CARE TOWARDS END OF LIFE

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  1. CARE TOWARDS END OF LIFE Dr. Tharanga Perera Consultant Anaesthetist BH- Wathupitiwela

  2. END OF LIFELikely to die within few hours, days or within the next 12 months.

  3. MRS. A – 60 YRS Diagnosed pt with bladder CA with multiple bone secondaries. Presented with fever, cough and acute SOB and low BP.

  4. Mr B – 80 YRS Diagnosed pt with Hypertension and CRF. Needs support in feeding ,mobilising and other basic needs. Presented with reduced UOP, confusion and a Pressure sore on the Left hip.

  5. MRS. C – 70 yrs Diagnosed patient with DM and LVF with frequent exacerbations. Independent with regard to feeding, mobilising inside house, and dressing up. Having lot of family support . Presented with acute severe SOB and chest pain.

  6. Mr. D – 30 YRS Fit and well man, met with a RTA. Patient is in the ICU Day 10, on ventilatory support, diagnosed to be in a persistent vegetative state.

  7. GROUP OF PATIENTS • Advanced, Progressive, incurable diseases • General frailty and co-existing conditions • Sudden catastrophic events • Persistent vegetative state (PSV) • Extremely premature infants

  8. AIM • Create awareness about this group of patients • How, and what type of care is needed • How to Support the patients as well as the relatives • Ethical and legal issues

  9. DECISIONS ON CARE ARE DIFFICULT • Clinically complex (Multiple acute and chronic conditions) • Emotionally distressing (Doctor Patient, Relatives, Medical Team) • Some may involve ethical dilemmas • Uncertainties about legal issues

  10. MOST CHALLENGING DECISIONS • Withdrawal of treatment (Not Care) • Not starting a treatment if it prolongs life Ex. Antibiotics CPR Dialysis Mechanical ventilation Clinically assisted nutrition (availability of resources)

  11. BEST FRAME WORK • Doctor and Patient making the decision together. • Capacity to decide at the time of presentation?

  12. ADULT WITH CAPACITY TO DECIDE • The Doctor and Patient make an assessment of the condition and make decision. Doctor • Specialist knowledge • Experience • Clinical judgement • Potential benefits and Risks of each option. • Patient should not be pressurized to accept.

  13. ADULT WITH CAPACITY TO DECIDE • PATIENT • Decision making capacity should be maximised. • Able to understand, retain and make the decision weighing the information given and to express the decision.

  14. ADULT LACKING CAPACITY TO DECIDE • Doctor makes the decision based on whether the treatment option will be of over-all benefit to the Patient • Advanced directives • Proxy • Previous wishes of patient.

  15. COMMUNICATION WITH RELATIVES • Doctor should respect their views and feeling as well. • Terminology and wording should be used carefully, • Poor communication leads to legal issues.

  16. PALLIATIVE CARE • Objective Support the Patient to live as well as possible until they die • Hydration • Nutrition • Management of distressing symptoms • Pain • Breathlessness • Agitation / Depression etc.

  17. CPR / DNAR Benefits of Prolonging Life Risks and burdens of Rx

  18. CPR / DNAR (Contd.) • Not only a clinical decision • Quality of life • Family support • Patient’s wishes If resuscitated – Is multi organ support in an ICU appropriate ?

  19. COMPLICATIONS OF CPR • Interventions are invasive • Forceful chest compressions - fractures • Electric shock • Injecting Drugs • Ventilation + Intubation • Hypoxic brain damage • Survive with disability • If unsuccessful patient dies in a traumatic undignified manner.

  20. ALLOW NATURAL DEATH • This will ensure last hours or days are spent in their preferred place of care with the preferred people. • Patient dies in a peaceful and dignified manner.

  21. How people die remains in the memory of who live on. Thank you.

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