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CEILING OF TREATMENT - Scottish Partnership for Palliative ...

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Professor D. Robin TaylorWishawGeneral Hospital
Case study
Male, 78 years, end-stage COPDSeveral admissions for over the previous year.Admitted with bronchopneumonia and respiratory failure.End of life conversation between myself, the patient and his family at 4pm. Acknowledged to be terminally ill.Agreed that medical treatment would be limited to oxygen, fluids,lorazepam, and morphine. This was documented.At 3 a.m. next morning, nursing staff noted the patient to be more breathless. In response, the on-call registrar commenced non-invasive ventilation (NIV) andaminophylline.Patient died 4 hours later. Family very angry.
Nobody documentedwhatnot to do!
Ceiling of Treatment
Common senseCommunicationCompassion
When are decisions …Futileand /orBurdensomeand / orContrary to the patient’swishes?
Ceiling of Treatment
Ceiling of Treatment
Designed …To improve management of acute episodes of deterioration in the context of an end-of-life trajectory.For use in hospitals to provide continuity of care and good communication.To provide information about, as well as appropriate limitations to interventions which are likely to be futile, burdensome, or contrary to the patient’s wishes.To be guided by discussions with patient and family or POA.To complement an Anticipatory Care Plan (ACP).
Assuming that other immediately reversible problems have beenaddressed (e.g. pneumothorax), management of the patient’sacute respiratory distressSHOULD ALWAYS INCLUDE SYMPTOMRELIEFe.g. low flow oxygen, opiates, haloperidol, benzodiazepine.Thereafter, the patient’s ACUTE MANAGEMENT MAY INCLUDE THEFOLLOWING: (Circle YES or NO. Changes can be made at any timelater if necessary).ARTERIAL BLOOD GAS ANALYSIS YES / NOANTIBIOTICS YES / NOPREDNISOLONE YES / NONON-INVASIVE VENTILATION (BiPAP) YES / NOTRANFER TO HIGH DEPENDENCY UNIT YES / NOICU / POSSIBLE MECHANICAL VENTILATION YES / NOCPR IN THE EVENT OF CARDIO-RESPIRATORY ARREST YES / NOActive consideration should be given to the need for spiritual care. ThisDocument should be used in conjunction with the Scottish National Guideline forPalliative Care in the Last Days of Life.
Ceiling of Treatment (Respiratory)
Ceiling of Treatment: NHS Lanarkshire
Piloted in Ward 7, WGHNow configured forCardiologyGastroenterology (Liver Disease)Advanced MalignancySurgeryHECT team study now under wayMedical and nursing training now under way
Reference:Taylor D.R.COPD, end of life and Ceiling ofTreatmentThorax2014; 69: 497-499.





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CEILING OF TREATMENT - Scottish Partnership for Palliative ...