Seizure management in children requiring palliative care

Controlling seizures in children approaching death can be difficult, and there is a limited evidence base to guide best practice | BMJ Supportive & Palliative Care

Objectives: We compared current practice against the guidance for seizure management produced by the Association of Paediatric Palliative Medicine (APPM).

Methods: Retrospective case note review of episodes of challenging seizure management in children receiving end-of-life care over a 10-year period (2006–2015) in the south-west region of England.

Results: We reviewed 19 admissions, in 18 individuals. Six (33%) had a malignancy, nine (50%) had a progressive neurodegenerative condition and three (17%) had a static neurological condition with associated epilepsy. Thirteen (72%) died in their local hospice, four (22%) at home, and one (6%) in hospital. Seventeen of 19 episodes involved the use of subcutaneous or intravenous midazolam infusion, for a mean of 11 days (range 3–27). There was a wide range of starting doses of midazolam, and 9/17 (53%) received final doses in excess of current dose recommendations. Six individuals received subcutaneous phenobarbital infusions, with four of these (67%) receiving final doses in excess of current dose recommendations. Plans for adjustments of infusion rates, maximal doses or alternative approaches should treatment fail were inconsistent or absent. In 16/18 (88%) cases seizures were successfully controlled prior to the day of the child’s death. Staff found the experience of managing seizures at end of life challenging and stressful.

Conclusions: Pharmacological approaches to seizure management in end-of-life care are variable, often exceeding APPM dose recommendations. Despite this, safe and effective seizure control was possible in all settings.

Full reference: Harris, N. et al. (2017) Seizure management in children requiring palliative care: a review of current practice. BMJ Supportive & Palliative Care. Published Online First: 7th July 2017

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Death certification reforms

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image source: http://www.gov.uk

Guidance: Changes to the death certification process This is an overview of the proposed introduction of medical examiners and reforms to the process of Death Certification in England and Wales.

The reforms are expected to be introduced from April 2018 and responses to the death certification reforms consultation will help to inform how these changes are put in place. You can also give your views by responding to the consultation.

Contents:

  1. Improving the death certification process
  2. Why the current system needs to change
  3. The reforms
  4. How the system will be improved
  5. Paying for the new system
  6. The new process
  7. Testing the reforms
  8. Professional standards and training
  9. Medical examiner recruitment
  10. Background: history of death certification
  11. Further information

End of Life Care

The National Palliative and End of Life Care Partnership which includes Care Quality Commission, Public Health England and the Association for Palliative Medicine has jointly published Ambitions for Palliative and End of Life Care: A national framework for local action 2015-2020. This guidance details the work that several organisations have agreed to do to improve local services, enabling people who use these services to have fair access to care, and that any care is based on individual needs.

ambition

Caring for People in the Last Days and Hours of Life: National Statement

In December 2013 the Scottish Government accepted the recommendation that the Liverpool Care Pathway (LCP) should be phased out in Scotland by December 2014. This statement confirms the current position.

Health and Care providers across Scotland are committed to the provision of consistently high quality end of life care for all that reflects the 4 principles set out in the guidance ‘Caring for people in the last days and hours of life‘ published at the end of 2013:

  • Principle 1: Informative, timely and sensitive communication is an essential component of each individual person’s care
  • Principle 2: Significant decisions about a person’s care, including diagnosing dying, are made on the basis of multi-disciplinary discussion
  • Principle 3: Each individual person’s physical, psychological, social and spiritual needs are recognised and addressed as far as is possible
  • Principle 4: Consideration is given to the wellbeing of relatives or carers attending the person