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- Identifying end of life patients
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- How to help your patients plan
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Professor Mayur Lakhani: my experience
Professor Mayur Lakhani is a practising GP and active appraiser in Leicestershire, and is also the Chair of the Dying Matters Coalition. He talks about an elderly patient who wanted to die at home, and the measures he put in place to help ensure the patient had his wishes met.
Last year, I saw a patient, an 80-year-old man, for acute exacerbation of chronic obstructive pulmonary disease.
He was accompanied by members of his family, who expressed concern that he was becoming frail and was deteriorating. His wife, who was also his carer, reported that he had developed faecal incontinence.
His problem list consisted of: atrial fibrillation; unspecified vascular dementia; depressive disorder; chronic obstructive airways disease; Ischaemic heart disease; and left ventricular systolic dysfunction.
The basis for putting him on the EOLC register was as follows: my answers to the 'Surprise questions' were 'No'; he had progressive life-limiting illnesses; he spent the majority of his time chair or bed-bound, needing more care; he had multiple medical conditions including COPD - short of breath at rest, Fev1 30%, low BMI; two recent unplanned admissions; worsening dementia and faecal incontinence.
What happened next
I initiated discussion (week 1) and arranged a meeting with his family (week 2), followed by a home visit (week 3). I simultaneously referred the patient to the community matron. An Advance Care Plan was put in place, as was a Preferred Priorities for Care (PCC), which stated the patient wanted to be cared for at home. A Do Not Resuscitate order was signed, as was the Out of Hours and EMAS (East Midlands Ambulance Service) notification: do not take to hospital.
What difference did this make?
The patient and his family welcomed having an open discussion and were relieved that the subject had been raised. Putting the patient on the register and creating a plan of care transformed the situation, giving both the patient and the family a great sense of relief. The patient's quality of life improved, and support for his wife, who was his primary carer, also improved through Marie Curie nurses.
After my first consultation with the patient, he had two out of hours contacts but no hospital admissions. He died, in his own home, in May of the following year surrounded by his family.
Triggers for end of life care conversations
If you find opening discussions about end of life difficult, the following conversation openers might help:
"What are your thoughts about the future? How do you see things going?"
"In thinking about the future, have you thought about where you would prefer to be cared for as your illness gets worse?"
"What do you see happening with your illness over the next few months?"
"It would be good to discuss what kind of medical care you would want if you should get sick again. How do you feel about talking about this?"
Professor Mayur Lakhani CBE FRCP FRCGP is a practising GP and active appraiser in Leicestershire. He was Chairman of the Royal College of General Practitioners from 2004 to 2007. For two years, 2006 and 2007, he was in the Health Services Journal (HSJ) Top 50 most influential people. He was the youngest elected Chairman at the age of 43. He is the principal author of the landmark document 'The future direction of general practice: a roadmap', in which he first advocated the idea of federations. Since its formation in 2009, Professor Lakhani has been Chairman of the Dying Matters Coalition.
- Dr Catherine Millington-Sanders
"Working with a deteriorating elderly patient to ensure he had the death he wanted" : View Dr Catherine Millington-Sanders' case study
- Case study: Dr Peter Nightingale
"Supporting a patient's dying wishes" : View Dr Peter Nightingale's case study