Terminal Care

- Always remember the legal framework within which you are working as well as the current status in
your career (responsibility increases as your career progresses)
- Things change over time – patients deteriorate quickly and what was appropriate yesterday might
not be appropriate today
- Decisions have consequences
- Remember the four basic principles: autonomy, beneficence, non-maleficence and justice

Prognostication
- Terminal care: care in the last few days/weeks of life. Some indicators include:
o Increasing weakness, loss of mobility
o Off food and fluids
o Drowsiness
o Bed-bound
o Semi-comatose
o Only able to take on sips
o No longer able to take on tablets
- In non-cancer scenarios it is a bit more difficult e.g. NHYA stage 4 HF has a poor prognosis
- Useful to rope in relevant clinical and radiological information
- Exclude reversible causes! Metabolic, infective and iatrogenic
- In the setting of cancer patients, performance indices are useful to indicate proximity to death
- It is important to diagnose people as dying or entering dying phase as one needs to answer questions
and make plans
- The uncertainty of prognosis in non-cancer disease makes way for new prognostic tools – consider
appropriate care pathways e.g. Liverpool Care Pathway. Rationale
o Any analytical approach to symptom control remains but becomes more clinical and
less investigative
o Consider route of administration
o Consider hydration/nutrition
o Consider essential and non-essential treatment
- SPICT tool – summarises the various factors used to prognosticate patients who are clinically dying
or not
o General factors
o Cancer / non-cancer setting
o In organ failure, erratic decline makes it much more difficult to predict
- Communication issues
o Reach out to individuals with prognostications; difficult in non-cancer situations and
children
 Medical Futility
- Treatment is futile if it does not conform to the patient’s goals, to legitimate goals of medical
practice or to accepted community standards. It may be futile if it is frequently ineffective
- Two types of medical futility:
o Quantitative – treatment DOES NOT WORK
o Qualitative – treatment is controversial for end supported. Treatment is successful in
achieving an end, but the end is not worth achieving (as defined by who?)
- Withhold/withdraw treatment related to disease; when and what to withdraw?
- Stopping treatment for comorbidities?
- Hydration and Nutrition in end of life (EOL)
o Bed bound patient lose smaller amounts of fluids
o Usually need 500 – 1000cc fluids per day
o Consider SC route (only saline as Hartman’s irritates the skin) – can be seen as not
totally neglecting patient but not too invasive
o Nutrition is less important, depending on the case
o Drive to eat is impaired
o Thirst needs to be defined (for patient? For family) – dry mouth? Doesn’t mean thirsty
- The accepted medical standards are not written in stone with respect to withdrawing/withholding
treatment at EOL – many times withdrawing treatment is not withdrawing treatment essential to life
- How futile is futile?
1. Measure size of benefit – quantitative (statistical) but also more than just numbers
2. Measure nature of benefit – case-by-case

Liverpool Care Pathway (of historical interest)

- A structured pathway of how to manage the imminently dying people

- The tool became too much of a tick-box framework that was seen to distort the ordinary
humanity of the doctor-patient relationship

 Withdrawing and withholding treatment is completely different from the doctrine of double
effect

Doctrine of Double Effect

1. The nature-of-the-act condition: the action must be either morally good or indifferent
2. The means-end condition: the bad effect must not be the means by which one achieves the
good effect
3. The right-intention condition: the intention must be the achieving of only the good effect,
with the bad effect being only an unintended side effect
4. The proportionality condition: the good effect must be at least equivalent in importance to
the bad effect
 When to carry out CPR?
- Case-by-case decision
- Conflict between healthcare practitioners themselves and between HCPs and patient/family
- Public think that CPR is a human right and a must
- It is always a question of perspective: HCP’s perspective and patient/family perspective
- Its good to ask:

1. Could treatment work?

 Predictable net gain
2. Is treatment available?
 BLS / ambulance / hospital
3. Is treatment wanted?
 Ideally the patient’s situation is explained to them, including their condition and their
chances of survival ect.. and put forward options, many times patients arrive to the
conclusion on their own
 Patients need appropriate information, space and time
- Its not only a question of successful CPR. It’s a question of survival to discharge. This can be
factored into the discussion
- Always remember the context and framework within which you are working

Some patients may which to receive CPR when there is only a small chance of success, in spite of
the risk of distressing clinical and other outcomes. If it is your considered judgement that CPR would
not be clinically appropriate for the patient, you should make sure that they have accurate information
about the nature of possible CPR interventions and for example the length of survival and level of
recovery that they might realistically expect if they were successfully resuscitated.

You should explore the reasons for their request and try to reach an agreement; for example, limited
CPR interventions could be agreed in some cases. When the benefits, burdens and risks are finely
balanced, the patient’s request will usually be the deciding factor. If after discussion, you still consider
that CPR would not be clinically appropriate, you are NOT obliged to agree to attempt in the
circumstances envisaged. You should explain your reasons and any other options that may be
available to the patient, including seeking a second opinion.