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Hot Topics Blog

Optimising end of life care with Daffodils

Simon Curtis - 18 Apr, 2019

Optimising end of life care for our dying patients has always been a high priority for primary care. It has simultaneously been one of the most rewarding and yet also challenging things that we do. When patients die an expected death in their own home, comfortable and pain free, surrounded by those that love them and with everyone prepared and understanding what is happening it is a success that lives long in the memories of those that are bereaved. And yet, although this may be the goal, things often seem to fail with last minute admissions, insufficient home care, lack of co-ordination or poor symptom control. How can we do better?

Improving end of life care has always been a Hot Topic, but it is now more so as it is a key part of the NHS Long Term Plan and central to this are the Ambitions for Palliative and End of life Care produced jointly by the NHS, the GMC, CQC and the royal medical colleges including the RCGP along with charitable partners. For GPs in England, it has become even more of a Hot Topic with end of life care being one of the two quality improvement domains in the new GP contract. This year to support this further for primary care teams, the Daffodil Standards have been published. This is an evidence based and structured approach developed by the RCGP and Marie Curie to help GP practices to offer the best end of life care for patients. For practices that sign up to the Daffodil standards (and they are free), they are recognised by the CQC and by the new NHSE GP contract as being a robust framework to provide evidence of quality of care.

The daffodil standards were discussed in an excellent BJGP editorial last year and were finally published earlier this Spring. As the BJGP paper points out, the pressures to provide optimal end of life care in the community are growing fast. It is estimated that the number of people needing palliative care will increase by 25% by 2040, with dementia and old age being the main drivers as well as cancer.

Traditionally palliative care has had a very medical model, focussing on control of biological symptoms. These new standards recognise that key to the success of end of life care requires much more than symptom control and syringe drivers. Whilst knowing how best to control pain, nausea, constipation, vomiting, hiccoughs etc is of course essential in reality palliative care often fails in the community because of psychosocial determinants such as loneliness, isolation, depression, anxiety and inability to manage. Early identification of dying patients, communication, and planning and delivering care that is personalised to the patient and in line with their wishes is of course key. But, to deliver this we will need the involvement and engagement of the whole primary care team and better collaborative working with outside agencies including the development of health and social partnerships with the voluntary sector and also the communities in which we work.

In many ways, the daffodil standards can be seen to de-medicalize palliative care and to broaden the agenda of care and in this respect they are very much in line with current themes of primary care such as working in partnerships, personalised care, advance care planning, social prescribing and psycho-social support as well as traditional medical and nursing care. Providing optimal end of life care is a huge responsibility, but it is not one that we should burden on our own and it is to be welcomed that these new guidelines recognise that.  

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Perinatal Mental Health Awareness

Stephanie De Giorgio - 30 Apr, 2019

Perinatal Mental Illness will affect up to one in four women from the time of conception until a year after birth. It is therefore hugely common, but sadly suicide remains the leading cause of death of women from 6 weeks to one year postnatally. 

As GPs we are very often the first person a woman will see if she is finding things difficult and it is so important to ensure that we are picking up all cases so that women receive the correct treatment. Research suggests that at the moment only 50% of women with a perinatal mental illness are being diagnosed and of those, only 50% are receiving the correct treatment. 

There has been a huge expansion of community perinatal mental health services across the country and there are also a team of GP champions to provide free education to you in your practice, contact me for more details. 

When doing postnatal checks or seeing women in the postnatal period make sure you give her every chance to disclose she is struggling.

As her “how are you finding being a mum (again)” and then “tell me about the birth” and really listen to the answers.

The good news, is that with the correct treatment, women can and do get better and the important mother/baby relationship can be enjoyed. 

There are some other golden rules to remember

  1. Don’t stop psychotropic medications in pregnant women without getting expert help. The risk of relapse is significant and the risk of an untreated mother is often greater than the risk of medication she effects. 
  2. Breastfeeding is not contraindicated in women taking medication, offer advice and support and contact your perinatal team, of UKTIS Bumps leaflets for further information (the BNF is not particularly helpful here).
  3. Women with bipolar disorder are at significant risk, up to 1 in 2, of developing puerperal psychosis. Refer these women for pre-natal advice from specialist team if possible and definitely discuss pregnancy at every medication review. 
  4. Puerperal psychosis is a medical emergency. Do not leave the woman unattended until she is under specialist care. 

If you want to learn more, come on the NB Medical Women’s Health Course with myself and Zoe Norris in London on 28th June and Birmingham on Tuesday 19th November. 

It is Perinatal Mental Health Awareness week from 29th April. The Perinatal Mental Health partnership is providing free sessions for women and professionals on our Facebook page on behalf of the Maternal Mental Health Alliance. There are lots of videos on there that both you and your patients may find useful from previous years and we will be doing more this year. For a preview of what the course has to offer, please click the link to view our perinatal mental health video

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