How do doctors communicate and make decisions about assisted hydration near the last days of life? A qualitative interview study

BackgroundThe impact of assisted hydration at the end of life is unclear and prevalence varies considerably worldwide. Little is known about optimal strategies for communicating and decision-making about this ethically complex topic. Hydration at the end of life is known to be an important topic for family members, but conversations about assisted hydration occur infrequently despite guidance suggesting that such conversations should occur with all dying people and those close to them.AimTo explore doctors’ views and experiences of communicating and making decisions about assisted hydration at the end of life.DesignSemi-structured qualitative interview study with framework analysis.Setting/participantsSixteen UK-based Geriatrics and Palliative Medicine doctors were recruited from a range of hospitals, hospices and community services, before and during the Covid-19 pandemic.ResultsParticipants reported clinical, practical and ethical challenges associated with this topic. The hospital setting provides several barriers to high-quality communication about assisted hydration at the end of life, which may contribute to the low incidence of documented assisted hydration-related conversations. Workplace culture in some hospices may make truly individualised decision-making about this topic more difficult. Exclusion of patients from decision-making about assisted hydration appears to be common practice.ConclusionsProactive, routine discussion with dying people about issues relating to hydration is indicated in all cases. There is room for debate regarding the limits of shared decision-making and the benefits of routine discussion of assisted hydration with all dying people. Clinicians have to navigate multiple barriers as they strive to provide individualised care.

Managing dying: multimedia end of life care simulation training for medical undergraduates

Background and IntroductionUK medical students consistently report feeling unprepared to look after patients in their last days of life.1 Junior doctors trained in the UK also frequently lack confidence in this key area of practice, in part due to a scarcity of undergraduate exposure to dying patients and associated decision-making.2 The COVID-19 pandemic has further reduced medical student opportunities to be involved in the care of dying patients and their families.MethodWe created a novel multimedia simulation, with participants playing the role of a F1 doctor managing a patient with advanced pancreatic cancer. We filmed actors in a replica ward environment to play the parts of the patient, their partner, a registered nurse, and a medical registrar. The final resource contained 48 video clips, 64 audio files, more than 200 pages of text, plus bespoke media items such as photographs, blood tests, and imaging results. The scenario was designed to unfold differently for each of the participants, depending on their individual decisions. This allowed them to make clinically significant mistakes in a safe way. In addition, real-time feedback was built in to optimise learning from patient assessment choices, medication rationalisation, anticipatory prescribing, and charged clinically assisted hydration discussions.Results164 final year medical students at the University of Cambridge completed Managing Dying in November 2020. Feedback was strongly positive, with several students reporting it was one of the most valuable learning experiences of their entire six-year course. Following completion, 92% of students reported feeling more confident about managing dying patients in the future.ConclusionMultimedia simulation can be an effective means of delivering undergraduate palliative care training. The format is particularly suited to providing students with experiences that are challenging to access otherwise, such as making patient-specific end of life care management decisions.ReferencesWells G, Youssef E, Winter R, et al. Medical student confidence in care of the dying and their family: a systematic review. BMJ Supportive & Palliative Care 2021;11:233–241.General Medical Council. Working in partnership to improve doctors’ preparedness for end of life care. Education and Training Advisory Board. 24 May 2016. Available at: https://www.gmc-uk.org/-/media/documents/4___Working_in_partnership_to_improve_doctors_27_preparedness_for_end_of_life_care.pdf_67192334.pdf

Cutting through complexity: the Breathing, Thinking, Functioning clinical model is an educational tool that facilitates chronic breathlessness management.

Chronic breathlessness is a distressing symptom that is challenging to manage. The Breathing, Thinking, Functioning clinical model is an educational tool developed to support breathlessness management. Health professionals report that the model increases clinician and patient understanding of this complex symptom, and provides a simple and structured approach to personalised self-management.

Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey.

BACKGROUND: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. AIMS AND OBJECTIVES: To investigate UK and Ireland clinicians' experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. METHODS: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. RESULTS: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. CONCLUSIONS: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.