11 - Advanced Care Planning

Question 1

What situations is there likely to be a deprivation of liberty?

Answer 1

• The person is subject to continuous supervision and control and
• The person is not free to leave

Question 2

What conditions need to be met in order for a DOLS to be put in place?

Answer 2

Need MCA

Question 3

What are the five key principles of the Mental Capacity Act?

Answer 3

1. Every adult is assumed to have capacity unless proved otherwise
2. A person must be given all practicable help to make their own decisions before they are deemed to lack capacity
3. Unwise, unsafe or dangerous decisions does not mean that person does not have capacity.
4. All treatment given to a person who lacks capacity must be in the patients best interests
5. Anything done for a person who lacks capacity must be done in the least restrictive way possible

Question 4

What 4 things does somebody need to be able to do in order to have full capacity?

Answer 4

Question 5

What is a Power of Attorney?

Answer 5

Legal document drawn up by a competent adult that nominates another person to make decisions on their behalf.

This can be related to financial and property, or health and welfare.

Can only be used when that adult has lost capacity.

Question 6

What is an Advance Directive?

Answer 6

Medical decision made by a patient with capacity, regarding their future wishes for treatment. Only comes into force if a patient subsequently lacks capacity

THIS IS LEGALLY BINDING!!!!

Question 7

What is the difference between an advanced statement and an advanced decision?

Answer 7

An Advance Decision only covers refusals of medical treatment

Advance Statement can include any information that you feel is important in relation to your health or care

Question 8

What is an Advanced Decision?

Answer 8

Short for Advanced Decision to Refuse Treatment, is a legally binding document.

Ensures an individual can refuse a specific treatment(s) that they do not want to have in the future

Question 9

What criteria needs to be met for an advanced decision to be legally binding?

Answer 9

Question 10

What is an Advanced Statement?

Answer 10

“Statement of Wishes and Care Preferences”.

General statements about their wishes, beliefs, feelings and values and how these influence their preferences for their future care and treatment

Not legally binding, but legally must be taken into consideration when making a “best interests” decision on someone’s behalf under the Mental Capacity Act (MCA)

Question 11

What are some things that may be included in an Advanced Statement?

Answer 11

Anything that is important to the individual e.g

​ - Religious or spiritual views

-​ Food preferences

• ​ Information about your daily routine
• ​ Where you would like to be cared for (in hospital, at home, in a care home etc.)

-​ Any people who you would like to be consulted when best interests decisions are being made on your behalf (however this does not give the same legal power as creating a Lasting Power of Attorney)

Question 12

What is a ‘ceiling of care’?

Answer 12

Maximum level of care which the patient is set to receive

This is because their chances of survival may be very low and subjecting the patient to further painful, undignified interventions for minimal gain in their quality or quantity of life would be unethical

Question 13

What things need to be considered in an EoL management plan?

Answer 13

• Review of poly pharmacy
• Take into account pt priorities
• Symptom control vs Curative treatment

Question 14

What is medical futility?

Answer 14

The proposed therapy should not be performed because available data show that it will not improve the patient’s medical condition

Ethical issue in DNAR decisions as often patients family want them to live as long as possible but do not understand this may be causing more harm

Good communication between Doctor and Patients/Families can help overcome issues with this

Question 15

What is age discrimination?

Answer 15

When a person is treated less favourably because of their age

Question 16

What strategies can be put into place to try and fight ageism in healthcare?

Answer 16

• Policy and Law
• Education Activities
• Intergenerational activities

Question 17

What are some life-sustaining treatments that may be withdrawn when a patient is end of life?

Answer 17

• Feeding tube
• Dialysis
• Ventilators

Question 18

What are some scenarios in end of life care that may need to have prescribed anticipatory drugs for symptom control?

Answer 18

• Pain
• Breathlessness
• Nausea and Vomiting
• Constipation
• Restlessness and Confusion
• Respiratory secretions

Question 19

What are some anticipatory drugs prescribed for pain in the palliative process?

Answer 19

• Morphine: First line. Monitor for constipation and unwanted sedation
• Diamorphine
• Oxycodone
• Alfentanyl: for patients with renal failure who cannot take morphine

Question 20

How do you calculate the dose of opioid to give for breakthrough analgesia in palliative care?

Answer 20

One sixth of the total daily dose

Question 21

How do you convert oral morphine to SC morphine?

Answer 21

Review every 24 hours

With 1/6 of this amount being PRN breakthrough!!!

Question 22

What are some anticipatory drugs prescribed for breathlessness in the palliative process?

Answer 22

• Therapeutic oxygen
• Morphine
• Midazolam

Question 23

What are some anticipatory drugs prescribed for N+V in the palliative process?

Answer 23

• Levomepromazine
• Cyclizine
• Haloperidol
• Metoclopramide

Question 24

What are some anticipatory drugs prescribed for restlessness in the palliative process?

Answer 24

• Haloperidol
• Levomepromazine
• Midazolam

Question 25

What are some anticipatory drugs prescribed for respiratory secretions in the palliative process?

Answer 25

* Hyoscine hydrobromide * Hyoscine butylbromide (doesn’t cross BBB and therefore less likely to cause drowsiness) * Glycopyrronium bromide

Question 26

Answer 26

Question 27

What are the 5 priorities of care when a person is dying?

Answer 27