ABSTRACT
Medically led, patient-centred, future care planning for patients predicted to be in their last year of life is possible on the complex care ward of an acute hospital, where patients often wait for social care placement into a nursing home. When the patient lacks the mental capacity to engage in the planning discussions themselves, meetings can take place between the multidisciplinary geriatric team and either those close to the patient or an independent mental capacity advocate. Participants in the meeting should use any existing advance care planning information, as appropriate, to develop 'best interests advice' (which can be referred to at a later date when a best interests decision needs to be made for the patient). Any future medical care plan should be reviewed for applicability and validity if the person's condition changes (improves or deteriorates), if the patient or those close to the patient request it, or 6-12 months after the initial plan is made. Education, training and support must be provided to ensure acceptance and understanding of the PEACE (PErsonalised Advisory CarE) process and general end of life care in the community. Specialist palliative care services are often best placed to provide this.
ABSTRACT
Many patients approaching the end of their life express the preference to die at home,[1] although unfortunately the majority of people will still die in hospital.[2] For patients approaching the end of their life, it was noted anecdotally that often those who have expressed a preference to go home from hospital for end of life care may have their discharge delayed due to problems in the prescribing of common medications used to alleviate distressing symptoms at the end of life. An initial audit at Conquest Hospital showed an 89% error rate in these prescriptions, mostly related to prescribing controlled drugs such as morphine and midazolam. A single standardised dispensing chart for commonly prescribed medications at the end of life, in the form of both "Just in Case" medications and syringe driver medications, was created which addressed this problem by having the medications pre-written so as to meet all legal requirements for controlled drugs. The prescriber is able to choose and fill out an appropriate drug and dose by using flow-chart information overleaf and then sign the prescription to allow it to be dispensed. After an initial two month pilot period, a re-audit showed a significant fall in error rate down to 11%, as well as an improvement in turnaround time in dispensing the medications.
ABSTRACT
BACKGROUND: Chronic cough is a disruptive and exhausting symptom, reported as very distressing in a quarter of those in their last year of life. Existing guidelines for management of chronic cough primarily deal with the commonest benign causes of cough: asthma; eosinophilic bronchitis; gastro-oesophageal reflux disease; rhinosinusitis. AIM/DESIGN: to examine what literature evidence exists and formulate recommendations for managing chronic cough in patients with advanced, progressive, life-limiting illnesses. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library, Google Scholar); hand-search; grey literature. RESULTS: Of 11 initially eligible studies, 5 provided evidence at level 2 or better. The small size of these studies, heterogeneity of study population and diversity of interventions and outcome measures used meant that comparison across studies and compilation of guidelines based on high-quality evidence was not possible. Pragmatic recommendations based on available evidence were formulated, drawing on the included studies and, in addition, extrapolating from two other well-designed studies involving patients with chronic cough. They also took into consideration convenience, toxicity and minimizing burden and harm of intervention, as well as considering the potential for disease-directed treatment and the possibility of pharmacological and co-existing benign causes of chronic cough. CONCLUSIONS: These recommendations (Grade D) include simple linctus, therapeutic trial of sodium cromoglycate and then prescription of an opioid or opioid derivative (dextromethorphan, morphine or codeine). Further research is clearly and urgently required in this area for more effective approaches to managing cough, tested in trials that have sufficient size, power and validity.
