palliative care in general practice 'Any
man's death diminishes me because
am involved in mankind Devotions Meditation
17, John Donne (1572-1631) Death is the natural
end to life-not a failure of medicine. Palliative
care starts when the emphasis changes from
curing disease and prolonging life to relieving
symptoms and maintaining well-being or
quality of life. On average, GPs have 1-2
patients with terminal disease at any time and
can get more personally involved with them
than other patients. End-of-life care (EOLC)
75% of deaths are predictable and follow a
period of chronic illness where end-of-life care
(for those likely to die in 12mo) would be
appropriate. Problems arising are a complex
mix of physical, psychological, social, cultural,
and spiritual factors involving both patients and
carers. To respond adequately good lines of communication and close multidisciplinary teamwork is needed. Local palliative care teams are invaluable sources of advice and support
and frequently produce booklets with advice on
aspects of palliative care for GPs. Symptom
control must be tailored to the needs of the individual. A few basic rules apply: Carefully
diagnose the cause of the symptom Explain
the symptom to the patient. Discuss treatment
options. Set realistic goals. Anticipate likely problems. Review regularly Identification It
may be difficult to identify when patients are
nearing end of life, particularly for non-cancer illness (see Figure 28.2). This can lead to access
to EOLC not being offered at all or being
offered late. Advanced care planning The 2008
National End-of-life Care Strategy recommends
assessment of people identified as approaching the end of life and agreement with them about how to meet their preferences using advanced care planning with regular review. This may include: Symptom control. Discussion about
preferences for care including do not attempt
to resuscitate directives (b p. 1052) Advance
directives to withhold treatment (b p. 123).
Discussion about preferred place of death-60 67% of people would prefer to die at home
currently 53% die in hospital but 40% have no
medical necessity to die there Communication
about EOLC People are more likely to talk about
end of life with their GP than any other
professional, but only 33% of GPs are confident
to initiate a discussion with a patient about
end-of-life issues. Specific training i
confidence.
Preferred priorities for care (PPC) The PPC
document is a tool for discussion and recording
of EOLC wishes. It is available to download from
the NIIS EOLC website. The Gold Standards
Framework Aims to improve quality of palliative
care provided by the primary care team by
improving the practice-based organization of
care of dying patients. The Framework focusses
on: optimizing continuity of care, teamwork,
advanced planning (including out-of-hours).
symptom control, and patient carer, and staff support. Evaluation data show the
framework i
the proportion of patients dying in their
preferred place and improves quality of care as
perceived by the practitioners involved.
Liverpool Care Pathway Is a model of best
practice to improve care of the dying in the last
hours/days of life. It covers physical,
psychological, social, and spiritual aspects of
care and widely used in the community, both in
care homes and in private residences. Over
recent years the Liverpool Care Pathway has
gained a controversial reputation as a 'pathway
to death but, if used correctly, with full
consultation with all medical staff and family
members/carers involved, it still has a very
important place in managing the final
days/hours of a patient's life. Further
information NHS National End-of-Life Care
Programme M
www.endoflifecareforadults.nhs.uk Dying
Mattress M www.dyingmatters.org NHS End- of-Life Care Programme Preferred Priorities for
Care M www.
endoflifecareforadults.nhs.uk/tools/core-
tools/preferred priorities for care Gold
Standards Framework M
www.goldstandardsframework.org.uk Liverpool Care Pathway M www.mcpcil.org.uk/liverpool care-pathway Help the Hospices Directory of hospice and palliative care services in the UK www.helpthehospices.org.uk/hospiceinformati
on Patient advice and support Macmillan Cancer Support F 0808 808 0000 M
www.macmillan.org.uk Cancer Function Organ
failure, eg. CCE, COPD Time Physical/cognitive
frailty Figure 28.2 Trajectories of decline at the
end of life