Dying from Lung Cancer

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Dying from Lung Cancer

• An audit of end of life care
• MARK SHIPLEY

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1) Standardised approach to end of life care (DNR
LCP)
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Top ten quality marker
DOH End of life care strategy quality markers
and measures for end of life care
http//www.dh.gov.uk/dr_consum_dh/groups/dh_digita
lassets/documents/digitalasset/dh_101684.pdf
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• 1) 100 of patients who die with lung cancer
  should have a standardised approach to end of
  life care, (for example, the Liverpool care
  pathway) including documentation of resuscitation
  decisions.

DOH End of life care strategy quality markers
and measures for end of life care
http//www.dh.gov.uk/dr_consum_dh/groups/dh_digita
lassets/documents/digitalasset/dh_101684.pdf
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2)Prescription of symptom controlling drugs
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Prevalence and Predictors of Symptoms in the
Terminal Stage of Lung Cancer A Community Study
Knut Skaug CHEST February 2007 vol. 131 no. 2
389-394

• Symptoms in last 48hrs lung cancer
• Pain 85
• Anxiety 71
• Dyspnoea 54
• Cough 24
• Nausea 21

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• In 100 of patients there should be prescription
  of symptom controlling drugs via appropriate
  route at appropriate dose.
• 2a) Opiate analgesia
• 2b) Antiemetic
• 2c) Antisecretory
• 2d) Benzodiazapine for anxiety

Ellershaw John and Ward Chris, (2003) 'Care of
the dying patient the last hours or days of
life.' BMJ, 326 pp30-34. The Liverpool Care
Pathway. http//www.liv.ac.uk/mcpcil/liverpool-car
e-pathway/
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3) Communication with patient and relatives
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• 3) In 100 of patients, if deemed to be in the
  dying phase then this should be communicated to
  the patient, and if appropriate, to the relatives
  (including resuscitation decisions.)

Ellershaw John and Ward Chris, (2003) 'Care of
the dying patient the last hours or days of
life.' BMJ, 326 pp30-34.
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Case Selection

• October 2008 September2009 at FRH
• Cases identified by Clinical Coding
• 35 Cases with Lung Cancer as cause of death
• 1 case excluded as died at QEH
• Notes obtained for 33 cases and were reviewed by
  MDS
• Cause of death confirmed on Death Certificates

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1) Standardised approach to end of life care (DNR
LCP)
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DNR Decisions

• 30 Patients DNR
• 22 Consultant decision
• 7 SPR decision
• 1 SHO decision

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Standardised approach to death
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24
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Conclusions

• 9/30 Patients with DNR decisions who died of lung
  cancer had a standardised approach to end of life
  care
• 1 patient for resususcitation as died post
  stenting
• 1 Patient deteriorated following sudden
  unexplained deterioration
• 1Patient no DNR ? Omission

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2)Prescription of symptom controlling drugs
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2a) Opiate analgesia
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Opiate Analgesia Choice
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Indication Documentation

• Opiates given in 18 patients
• Indication documented in 6 patients
• In all patients where indication was documented
  opiates were given

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2b)Benzodiazepines for Anxiety

• Prescribed in 24 patients - Given in 21
• Indication in 6 (4 given)

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2c) Antiemetics
Anti-emetics given In 6 patients Indication in 4
( Given in 50)
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2d) Antisecretion

• Hyoscine 400mcg s/c prescribed in 12/33
• Indication documented in 1
• Given in 5 patients

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Prevalence and Predictors of Symptoms in the
Terminal Stage of Lung Cancer A Community Study
Knut Skaug CHEST February 2007 vol. 131 no. 2
389-394

• Symptoms in last 48hrs lung cancer
• Pain 85
• Anxiety 71
• Dyspnoea 54
• Cough 24
• Nausea 21

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Prevalence and Predictors of Symptoms in the
Terminal Stage of Lung Cancer A Community Study
Knut Skaug CHEST February 2007 vol. 131 no. 2
389-394

• Symptoms in last 48hrs lung cancer
• Pain 85
• Appropriate Analgesia 66
• Anxiety 71
• Appropriate Antianxiety 68
• Dyspnoea 54
• indication documentation?
• Cough 24
• Appropriate Antisecretory 15
• Nausea 21
• Appropriate Antiemetic 18

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3) Communication with patient and relatives
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Communication

• End of life discussed with patient in 13/31
• 1patient admitted unconscious
• 1patient deteriorated after falling causing LOC
• Discussions with family 26/33

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Conclusions

• Despite patients with lung cancer being
  identified as approaching end of life (By DNR) a
  standardised approach to end of life care is only
  used in 24
• Anticipatory prescribing is variable, indications
  are rarely documented and use of drugs is low
• Increasing indications may increase drug use
• End of life is often not discussed with patients
• Discussions are twice as likely to occur with
  relatives