Minutes of the Exeter Sessional GPs Group
at Darts Farm – 7 February 2012
The meeting was kindly sponsored by:
Fran Holmes ProStrakan
Jess Owen
Grunenthal
Attendance:
38 members
Welcome:
Hamish Duncan opened the meeting, thanking the reps., reminding all to sign the
register and introducing the speaker Dr Lucy Smyth, Renal Consultant RDE.
Renal end of life care – Liaison with the Community Dr Lucy Smyth
Renal end of life care was mentioned in Renal National Service Framework 2005.
National documents available on line:
End of Life Care Strategy 2008
End of Life Care in Advanced Kidney disease 2009
In the past tendency has been to continue aggressive management and then suddenly
change over to palliative management at a fairly late stage.
Now there is a push to have a gradual reduction in aggressive management and
gradually introduce palliative management with time.
In terms of illness trajectories the traditional trajectory for renal disease has been that
of high function to a fairly late stage then a sudden decline – but in fact trajectories
are much more variable – there can a gradual decline punctuated by sharper declines
with recoveries more often associated with heart disease or a long and slow decline
more often associated with frailty of old age.
Median age to start dialysis in UK is 65 years and in Exeter is 73 years. More than
half have one or more co morbidities. Life expectancy is 3.9 years for those starting
dialysis between ages 65-69 – i.e. prognosis is very poor. 15% of those with
advanced kidney disease choose conservative management – prognosis is months,
although may out live their life expectancy on dialysis. 10-15% withdraws from
dialysis – median survival is eight days after stopping dialysis.
Five year survival stage 5 CKD is 23.2% on renal replacement treatment at age over
65 – much worse than most other chronic illnesses and many malignancies.
Conservative kidney management:
 Low clearance clinics (eGFR < 20)
 Information about renal replacement treatment vs conservative
 Anaemia / mineral bone disease / dietary / fluid management
 Advance care planning
Fluid management:
 Diuretics – aim for patient comfort, balance cardiac and renal, may need large
doses diuretics – e.g. 500mg furosemide daily, accept that creatinine will rise
 Salt and water restriction
 Shortness of breath may be due to acidosis – can use sodium bicarbonate, but
beware salt load
 Hypertension – may be a sign of fluid overload
Lethargy:
 Uraemia
 Anaemia – IV iron +/- EPO – try to keep ferritin>150mmol/l and Hb>10.5
 Nutrition – high risk of malnourishment – may need dietary restriction of
potassium and phosphates
Itch:
 Correct high phosphate and parathormone – diet, phosphate binders,
alfacalcidol
 Emollients – Balneum. Also EuraxHC.
 Antihistamines
 Cool clothes
Restless legs:
 Clonazepam
 Pramipexole
Nausea:
 Cyclizine
 Metoclopramide at reduced dose 10mg bd max to avoid extra pyramidal side
effects
 Haloperidol helpful in later stages, but is sedating
Hyperkalaemia:
 Treat until late stages
 Dietary modification
 Stop ace inhibitors or angiotensin receptor blockers
 Use sodium bicarbonate
 Is usually the ultimate cause of death
Identifying patient near end of life:
 At time of decision to treat conservatively
 Deteriorating despite dialysis
 Crisis – e.g. CVA, MI
 Other life limiting condition diagnosed e.g. malignancy
 Failing transplant and not returning to dialysis
 The “surprise” question – would you be surprised if the patient died in the next
12 months?
Prediction of poor prognosis:
 Older
 Dementia
 Peripheral vascular disease
 Low albumin
 Answering no to surprise question
Cause for concern register:
 Identify patient approaching end of life
 Allows communication and co-ordination of care – regular multi disciplinary
team review, liaison with GP and community teams, gold standard framework
 Incorporate into locality palliative care register
 Link in with advanced care planning
Who to put on register:
 Patients managed conservatively
 Patient asked to stop renal replacement treatment
 Already been identified by GP and on Gold Standard Framework
 In bed more than half the time
 Two or more non elective admissions in last 3 months
 Increasing problems with dialysis e.g. running out of access options
 Increasing frailty
 New significant co-morbidity e.g. malignancy
 Multiple significant co-morbidity
 Answer no to surprise question
Advanced Care Planning:
 Draw up jointly – patient, carers, health care team especially renal team
 An ongoing process
 Preserved Priorities of Care documentation
 Information held on Adastra
 Available to all who need it
 Time and sensitivity
Canadian study showed that many patients regret having started dialysis.
Place of death – a lot of haemodialysis patients prefer to die in hospital – feel secure
having become accustomed to the environment during their dialysis.
Dialysis withdrawal:
 Palliative dialysis may be appropriate
 Should be ongoing discussion
 Allow time for discussion and thoughts
 Involve family if possible
 If patient lacks capacity then it is much easier if wishes known – Advanced
Care Plan. Professionals need to help family make decision based on what
they feel the patient would want.
Care of dying:
 Consider needs of patient and carers
 Shared information – palliative care register
 Advanced Care Plan
 Preferred place of care
 Rapid response pathway for in patients
 Avoidance of unplanned admissions
 “Do not attempt resuscitation” documentation
 Pain and symptom management – specific Liverpool care pathway for renal
patients, anticipatory care, just in case boxes.
Renal Liverpool care pathway:
 Preference for Fentanyl or Alfentanil for pain and dyspnoea, patches can help,
start s/c at 25mcg prn. Oxycodone 1-2mg s/c prn can be used. Try to avoid
morphine – metabolites accumulate leading to agitation and restlessness and
response is unpredictable – if only option then 1.25-2.5mg s/c prn.
 Midazolam for agitation – 2.5mg s/c prn
 Glycopyrrhonium for secretions – start at 200mcg s/c – the alternative is
hyoscine butylbromide
 Haloperidol works well for nausea
Organisation:
 Clinical leads – medical and nursing
 Renal end of life care nurse
 Link nurses in haemodialysis and renal community nurse teams
 Designated patient key workers
 Links with community teams
 Staff training – of renal team and of GP / palliative care team
Set up community links:
 Adastra palliative care register
 Renal end of life nurse
 GP end of life facilitator
Need education sessions for GPs, palliative care teams, district nurses, pharmacists –
to ensure drug availability.
Housekeeping
Hamish thanked Dr Smyth for the informative talk and reminded members to sign the
attendance register.
Future ESGPG Meetings
March 6th - Dr Anna Hinton, Geriatrician- Fits, faints and giddiness
April 3rd – Dr Katarina Kos, Endocrinology Consultant- Obesity service.
May 1st – Mr Ian Sharp, Consultant Orthopaedic Surgeon – Foot and ankle problems
June 12th (change of date due to Diamond Jubilee Bank Holiday) – Dr Jim Hart,
Consultant Paediatrician – Infant feeding problems and D+V
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Hamish Duncan (chairman and LMC link)
Dr Diane Baker (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
Dr Katherine Wood (funding co-ordinator)
Dr Caroline Burton (treasurer)
Dr Kathryn Shore (minutes secretary)
Dr Clair Homeyard (social secretary)
Dr Francesca Vasquez (social secretary)
Dr Megan James (LMC link)
hamishduncan@hotmail.com
dianebaker625@hotmail.com
nimitagandhi@nhs.net
katherine.wood2@nhs.net
c_burton74@hotmail.com
kathrynshore@btinternet.com
clair_homeyard@hotmail.com
cesca1@hotmail.com
daniel@dbbyles.wanadoo.co.uk