Dr Daisy Salt is a salaried GP in Winchester and a specialty doctor in hospital palliative medicine
Key points
- Try to have honest conversations early in the illness journey – and establish what is most important to the patient
- Project forward to the likely trajectory and mode of dying to try to anticipate problems
- Arrange anticipatory medications if the patient is likely to die within the next six months
- Consider medication options if the patient is likely to be unable to take treatment orally
- Take account of renal and hepatic impairment when considering dosages
- Use an end-of-life check list to ensure all the relevant organisational bases are covered
Everyone we love, every one of our patients, every one of us will die. That’s why competent and compassionate end-of-life care is essential.
General practice has always managed death and dying, but with patients living longer and having more complex health needs, this sometimes becomes more challenging.
Now that half of patients choose to die in the community at their usual place of residence instead of in hospital, it has never been more important that we get it right – especially as revelations of opioid misuse at a hospital in Hampshire have undermined the trust between patients and medical professionals.
This adds to the biggest challenge of delivering good end-of-life care in the community – time. General practice is pressured like never before and providing care to dying patients can be time consuming.
But good end-of-life care should not be difficult. Investing just a few minutes in the start of a patient’s dying trajectory can help you plan properly and avoid time-consuming crisis management.
Here are things to keep in mind.
1: You can always do something
When someone is dying, it is easy for both relatives and health professionals to feel helpless. After all, relatives want to support their loved ones and health professionals have been programmed to ‘fix’ people.
While medical and pharmacological expertise is important, it may not always alleviate suffering. Often, as people near death, distress and agitation can be caused by simple things beyond their physical symptoms. The gardener who wants to smell his flowers again may settle when a window is opened, and the matriarch wrestling to stay alive may relax and let go after her child returns home from abroad. Understanding the importance of simple kindness in end-of-life care is as fundamental as all the medical knowledge we
may possess.
The huge advantage that GPs have in delivering end-of-life care is a detailed knowledge of patients and their families. If you understand that Mrs Smith never goes anywhere without her corgi, you may avoid giving unnecessary drugs to manage agitation by bringing the dog to the bedside.
The key to understanding death and dying is to appreciate that it is a journey, walked differently by every person. Learning about our patients and what drives them is the best way to deliver good end-of-life care.
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