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End-of-life care in a psychiatric hospital

  • Lauren Z. Waterman (a1), David Denton (a1) and Ollie Minton (a2)
Summary

Since the Liverpool Care Pathway has been withdrawn in the UK, clinicians supporting the palliative needs of patients have faced further challenges, particularly for patients with dementia who are unable to go to a hospice owing to challenging behaviours. It is becoming more important for different services to provide long-term palliative care for patients with dementia. Mental health trusts should construct end-of-life care policies and train staff members accordingly. Through collaborative working, dying patients may be kept where they are best suited. We present the case study of a patient who received end-of-life care at a psychiatric hospital in the UK. We aim to demonstrate how effective end-of-life care might be provided in a psychiatric hospital, in accordance with recent new palliative care guidelines, and highlight potential barriers.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Lauren Waterman (laurenzwaterman@doctors.net.uk)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 National Council for Palliative Care. Commissioning End of Life Care: Act and Early. Initial Actions for New Commissioners. NCPC, 2011.
2 Leadership Alliance for the Care of Dying People. Once Chance to Get it Right: Improving People's Experience of Care in the Last Few Days and Hours of Life. LACDP, 2014.
3 World Health Organization. Dementia: A Public Health Priority. WHO, 2012.
4 Alzheimer's Disease International. World Alzheimer Report 2010: The Global Economic Impact of Dementia. International Federation of Alzheimer's Disease and Related Disorders Societies, 2010.
5 Meeussen, K, Van den Block, L, Echteld, M, Boffin, N, Bilsen, J, Van Casteren, V, et al. Older people dying with dementia: a nationwide study. Int Psychogeriatr 2012; 24: 1581–91.
6 Van Uden, N, Van den Block, L, van der Steen, JT, Onwuteaka-Philipsen, BD, Vandervoort, A, Vander Stichele, R, et al. Quality of dying of nursing home residents with dementia as judged by relatives. Int Psychogeriatr 2013; 25: 1697–707.
7 Vandervoort, A, Van den Block, L, van der Steen, JT, Volicer, L, Vander Stichele, R, Houttekier, D, et al. Nursing home residents dying with dementia in Flanders, Belgium: A nationwide post-mortem study on clinical characteristics and quality of dying. J Am Med Dir Assoc 2013; 14: 485–92.
8 van der Steen, J, Radbruch, L, Hertogh, C, Boer, M, Hughes, J, Larkin, P, et al. White paper defining optimal palliative care in older people with dementia: a Delphi study and recommendations from the European Association for Palliative Care. Palliat Med 2014; 28: 197209.
9 European Commission. The 2014 EU Summit on Chronic Diseases: Conference Conclusions. European Commission, 2014.
10 Neuberger, J, Guthrie, C, Aaronovitch, D. More Care Less Pathway: A Review of the Liverpool Care Pathway. Department of Health, 2013.
11 NHS England. Guidance for Doctors and Nurses Caring for People in the Last Days of Life. National Council for Palliative Care, 2013.
12 National Council for Palliative Care. Capacity, Care Planning and Advance Care Planning in Life Limiting Illness. NCPC, 2011.
13 Annear, M, Toye, C, McInerney, F, Eccleston, C, Tranter, B, Elliott, KE, et al. What should we know about dementia in the 21st century? A Delphi consensus study. BMC Geriatrics 2015; 15: 5.
14 Henry, C, Seymour, J, Ryder, S. Advance Care Planning: A Guide for Health and Social Care Staff. University of Nottingham, 2007.
15 General Medical Council. Treatment and Care Towards the End of Life: Good Practice in Decision Making. GMC, 2010.
16 Robinson, A, Eccleston, C, Annear, M, Elliott, KE, Andrews, S, Stirling, C, et al. Who knows, who cares? Dementia knowledge among nurses, care workers, and family members of people living with dementia. J Palliat Care 2014; 30: 158–65.
17 van der Steen, JT. Dying with dementia: what we know after more than a decade of research. J Alzheimers Dis 2010; 22: 3755.
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BJPsych Bulletin
  • ISSN: 2056-4694
  • EISSN: 2056-4708
  • URL: /core/journals/bjpsych-bulletin
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End-of-life care in a psychiatric hospital

  • Lauren Z. Waterman (a1), David Denton (a1) and Ollie Minton (a2)
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eLetters

Author Reply: Response to Dr Waite

Ollie Minton, Consultant in Palliative Medicine, St George's University NHS Foundation Trust
04 July 2016

We thank Dr Waite for alerting readers to further useful guidance on advanced care planning. While we agree that there is much to be done from the 2009 Royal College of Physicians report, we have chosen to address the aspects of Mrs S' end-of-life care. In particular, we have focused on the synergies between the psychiatric staff and the local hospice.

On one particular point we stated that people can express their wishes about preferred place of treatment in an advanced decision. However, we never stated that an advanced decision is always binding - on the contrary, we said that Mrs S' was invalid.

The debate raised around Burke vs GMC is around providing treatment 'not' in a patient's best interests and is not directly relevant to our paper.

However, Dr Waite's final broader point that "ascertaining how patients would like to be treated when they are unable to make decisions for themselves should be part of routine practice with all psychiatric patients" is welcomed.

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Conflict of interest: None Declared

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Guidance on advance care planning

Jonathan Waite, Consultant psychiatrist, Nottinghamshire Healthcare Foundation Trust,
30 June 2016

Waterman et al (1) perform a useful service in drawing attention to the need for psychiatric in-patient units to develop expertise in terminal care. It is a shame that they have not acknowledged the guidance on advance care planning developed by the Royal College of Physicians (2) in conjunction with the Alzheimer’s Society, the Royal College of Psychiatrists, and other lay and professional groups.

The authors have also misunderstood the status of advanced decisions to refuse treatment made under the Mental Capacity Act 2005. To be valid, an advanced decision must specify a particular treatment which is not to be carried out or continued (3). It is not possible to make an advance decision to die at home and not go into residential care (although it would not be possible to use the Deprivation of Liberty Safeguards to require a person to stay in hospital to receive treatment that had been refused in advance). It is not possible to require health care professionals to provide a specified treatment (4).

It is best to regard advance care plans as statements of wishes and feelings about what is in the patient's best interests. The Mental Capacity Act places particular emphasis on relevant written statements made by the patient when he/she had capacity (5). There are likely to be times when most psychiatric patients will lose capacity to make some decisions. Ascertaining how patients would like to be treated when they are unable to make decisions for themselves should be part of routine practice with all psychiatric patients.

References

1 Waterman LZ, Denton D, Minton O. End-of-life care in a psychiatric hospital. BJPsych Bull 2016; 40: 149–152.

2 Advanced Care Planning: National Guidelines. Royal College of Physicians, 2009. Available at: https://www.rcplondon.ac.uk/guidelines-policy/advance-care-planning

3 Mental Capacity Act 2005 s.24

4 R (Burke) v GMC [2005] EWCA Civ 1003

5 Mental Capacity Act 2005 s.6(a) – see also Mental Capacity Act Code of Practice para 5.40-5.45.

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Conflict of interest: JW has been appointed as a Court of Protection Special Visitor under s.61 of the Mental Capacity Act.

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