Mrs Betty Gold A home visit Betty Gold

Mrs Betty Gold A home visit

Betty Gold • 78 year old woman who lives with her son • Advanced heart failure • Also has atrial fibrillation, hypertension and osteoarthritis • Her son Tony requests a home visit to review worsening leg swelling • 2 emergency admissions to hospital in the last 6 months (UTI and exacerbation of heart failure)

At Betty’s home • Betty is sat up in an armchair • She reports being less mobile over the last few months and spends most of the day sitting • Tony is concerned that she is not eating much and has lost weight • They have no external carers and Tony helps her with washing and dressing.

According to the SPICT criteria, which features of the history so far suggest that Betty’s prognosis may be less than 12 months?

https: //www. palliativecarescotland. org. uk/content/publications/Identi fying-SPICT-poster. pdf

Current medication • Bisoprolol • Amlodipine • Warfarin • Furosemide • Atorvastatin • Ibuprofen PRN Which of the drugs above might be contributing to her leg swelling?

The following drugs may be contributing to her leg swelling: • Amlodipine • Ibuprofen PRN

On home visit • No dyspnoea at rest • Not confused • Denies any chest pain • Moderate bilateral oedema both lower legs • Mild bi-basal crepitations on auscultation of chest • Temp 37, pulse 80 irregular, BP 128/ 94, RR 20/min, O 2 sats 94% on air

• What classification system can be used to grade the degree of breathlessness due to heart failure symptoms?

• The New York Heart Association (NYHA) Functional classification of breathlessness is a useful tool for assessing dyspnoea in heart failure patients • Not to be confused with the MRC dyspnoea scale for COPD patients! http: //www. practicenurse. co. uk/index. php? p 1=a-z&p 2=shortness-ofbreath

What can you do to optimise her management? Current medication (she is on the recommended doses) • Bisoprolol • Amlodipine • Warfarin • Furosemide • Atorvastatin • Ibuprofen PRN

Optimising her management • Stop the amlodipine and ibuprofen • Ask her to try to keep her legs elevated • Arrange bloods to check U&Es/ LFTs/ FBC • Consider starting an ACE inhibitor

You ask Betty how she is feeling in general and she replies……… “ Not too bad doctor, Tony takes good care of me. But I know I’m getting frailer and am not going to be around forever”. Dr: “Does this concern you? ” Betty: “To be honest I am a bit worried about how we will manage in the future when I get worse. I don’t want to be messed about with in hospital again or go into a nursing home. ”

Dr: “Have you thought about where you would like to be cared for if you become more unwell in the future? ” Betty: “At home, but I am worried about how Tony would manage. Maybe it would be okay if we had some help? ”

What support could be offered to Betty and her son to allow her to stay at home?

A multidisciplinary team approach • Social services to look at a package of care • Physiotherapy to help improve mobility • Occupational therapy to consider adaptations to help • Offer day hospice for social support • Offer respite care to enable son to have a break

Betty is surprised when you mention the hospice “Isn’t that just a place that looks after people who are dying? ” How would you explain what services the hospice provides?

Hospice Services provided in most hospices include: 1. 2. 3. 4. 5. End of life care Symptom control Respite care Day hospice Psychological therapies

Hospice • Most hospices can only provide short term placements • Care is free at the point of entry for patients • In general hospices are funded by the NHS and charitable donations • Tends to be a more relaxed, homely atmosphere compared with hospices with less strict visiting times etc

You decide that it is appropriate to carry out some Advanced Care planning. What topics should be covered?

Advanced Care Planning • Preferred place of care • Preferred place of death • Advanced decisions to refuse treatment • Resuscitation status • Lasting power of attorney • Will May need several consultations to cover all the above!

Advance care planning communication skills Please roleplay with your partner the following scenario: • One of you is the GP and one of you Betty Gold • Explain what a Do not resuscitate order is and explore the patient’s thoughts about resuscitation and whether or not they consider this order is appropriate for them.

A good example of how to discuss resuscitation orders with patients https: //www. youtube. com/watch? v=1 k. XHh. ZK_lv 0