STEMI

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by Jack Holmes1 view·Updated Jan 18, 2022
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  1. can an acute stem me be discharged on scene?
  2. The ethics of end of life Advanced care plans.
  3. I'll be using the Graham Gibbs 1988 model,
  4. a 96 year old female presents with one episode
  5. of vomiting whilst having lunch in a care home.
  6. On arrival, the patient is sitting in a reclining armchair
  7. only responsive to pain,
  8. with a normal work of breathing and a pale skin tone.
  9. I also stated the patient's chest
  10. and her chest was clear.
  11. She was here, know him Oh, dynamically stable and had no signs of infection.
  12. I decided to do a 12 lead, E C. G,
  13. and this is shown here.
  14. As we can see, the patient is having an inferior stem. E.
  15. The patient had no cardiac history.
  16. The patient did, however, have an advance care plan
  17. and a valid DNA CPR. Due to a number of comorbidities.
  18. This advanced care plan stated to avoid any hospital
  19. admission and to prevent any new medical interventions.
  20. The patient also had a lasting power of attorney for health and
  21. welfare who was an old friend of hers who lived close by.
  22. So why did this patient have an advance care plan,
  23. perhaps to reduce uncertainty,
  24. to prevent unwanted treatment,
  25. to prevent unwanted hospital admission
  26. and to determine her future goals at the end of her life.
  27. Florin looked into this a bit further
  28. in a systematic literature review,
  29. finding that the overarching theme to advance
  30. care plan are respecting an individual's autonomy,
  31. improving the quality of care,
  32. strengthening relationships,
  33. preparing for the end of life
  34. and reproducing overtreatment.
  35. Yeah,
  36. I felt quite unexperienced at this job
  37. as I knew the patient had an advance care
  38. plan but was also having a serious medical event.
  39. Therefore, I scared of saying the wrong things. I won't get it right.
  40. I didn't want to jump to saying that she should go to hospital and I
  41. didn't want to jump to say we should follow follow the advanced care plan.
  42. I was quite coach of the ethics around it
  43. as it had been discussed at university before.
  44. I was aware this was much more significant than just a clinical presentation
  45. and deciding maybe to take her to hospital or not,
  46. as this could be the end of her life,
  47. Craig said.
  48. Influencing one's end of life treatment choices
  49. when no longer competent to communicate consent
  50. could be perceived as the final act of autonomy.
  51. Mhm.
  52. Yeah,
  53. As a crew, we decided it would be against the patients.
  54. Advanced care plan to follow disgustingly pathway and
  55. convey the patient to a PPC our unit.
  56. I phoned the patient's lasting power of attorney.
  57. He was able to immediately come to the nursing
  58. home and be involved in the decision making.
  59. I spoke to him in his state that he wanted our
  60. patients be made comfortable and to be kept at the home,
  61. saying
  62. she's had a good life. I would want to stay here.
  63. Mhm,
  64. Yeah,
  65. To support this decision making, I phoned the patient's own GP
  66. who agreed that would be
  67. inhumane to take the patient's hospital
  68. with the GP and the nursing staff.
  69. I arranged for end of life medication to be prescribed
  70. to make the patient come to in her death
  71. as by the jail couch and nice guidelines.
  72. Okay,
  73. yeah,
  74. a brief history of advance care plans.
  75. Advanced care planning was introduced in response
  76. to the Medical Capacity Act 2000 and five
  77. to replace terminology such as living wills.
  78. It was introduced to prepare individuals for deterioration in their health
  79. and to allow them to have a say once they lack capacity.
  80. Mhm.
  81. Yeah,
  82. The gold standard framework suggests
  83. that an advance care plan should include
  84. What do you want to happen?
  85. What don't you want to happen
  86. and who will speak for you?
  87. I think these were all clearly laid out in the patient's advance care plan.
  88. Mhm.
  89. Mhm.
  90. What does the research say
  91. in a randomised controlled trial? By debt uttering,
  92. they compared wishes respected
  93. in patients with an advance care plan.
  94. They found that when a patient had an advance care plan,
  95. their wishes were
  96. respected in 86% of patients
  97. in comparison to 30% of patients that did not have an advance care plan.
  98. They also found that the families of the intervention arm
  99. were found to have lower levels of psychic psychological morbidity.
  100. These questionnaires allowed researchers to collect qualitative accounts
  101. in a systematic way using these control groups.
  102. This creates a high level of validity.
  103. Yeah,
  104. this randomised control trial had a large sample size of 800 patients.
  105. It's allowed for an insight into both the patient's experience
  106. and the families experience. Once the patient had died.
  107. This therefore allowed the primary and secondary outcome.
  108. Birthday
  109. measured,
  110. they found consistent results so in good reliability in their methodology.
  111. This study
  112. made recommendations to healthcare providers
  113. in how to improve advance care plans in local areas.
  114. They found a reduction in stress, anxiety and depression in the family members
  115. in which patients had an advance care plan.
  116. A limitation to this study is that they excluded non English speakers.
  117. If they included English, non English speakers,
  118. it could have investigated cultural differences.
  119. Therefore, this limitation reduces generalise ability
  120. of results.
  121. Another limitation
  122. is the questionnaire researcher was blinded
  123. to the interventions used
  124. to increase validity.
  125. However, when
  126. coding the questionnaires,
  127. it became obvious which group
  128. the question as had come from.
  129. Perhaps the methodology could have been improved to reduce the validity.
  130. Increase the validity of the experiment.
  131. Alongside this, it was a single centre study
  132. which could
  133. reduce generalist ability
  134. due to the logical and cultural differences.
  135. Yeah,
  136. Secondly, I
  137. can't write a towel. Found major knowledge gaps among medical specialties.
  138. They found that palliative and geriatric specialties
  139. developed developed, showed the greatest knowledge
  140. and most positive attitude towards the law.
  141. This could probably be expected.
  142. The limitation to this study as it was performed in Australia,
  143. perhaps the healthcare system, the NHS would not have bigger knowledge gaps.
  144. Mhm
  145. reflecting on this job highlighted the importance
  146. of being realistic about patient's outcome.
  147. While start the job allowed me to practise professional judgement,
  148. considering the patient's individual circumstances,
  149. it's highlighted my own inexperience and
  150. the importance of collaborative decision making
  151. with the paramedic owes with
  152. the lasting power of attorney
  153. and the patient's GP.
  154. It allowed me to take time planning further care
  155. for the patient, including the new end of life medications.
  156. I need to familiarise myself with the legalities surrounding advance care plan.
  157. Also need to develop my knowledge on local variation advanced care planning,
  158. for example respect forms in some local areas.
  159. Here are the references of the studies discussed in the presentation.
  160. Thank you.