... Feathers ... Light ... Corners

INDIVIDUAL
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INTERPERSONAL    :     SCIENCES             
HUMANISTIC --------------------------------------  MECHANISTIC   
SOCIOLOGY  :   POLITICAL
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GROUP

I love you mum You named me 'Peter' ... Grief, is indeed -	Yesterday, I saw a kestrel and a sparrow hawk .                          . - a thing with feathers
... but it was always you, you are still - the rock - my rock - the reason I'm a nurse ... family community humanity	... and why I will continue to explore and follow ...

"Using Hodges’ model to prove light can travel around all the methods corners" ...

I cannot see you but I know you are there Crux.

Anticipatory Prescribing as part of Anticipatory Care

This post is derived from a selection of the main concepts found within three papers (references listed below) on 'anticipatory prescribing'. Some explanation may assist. I have duplicated 1. What is current practice? across the domains to suggest that the question needs to be answered for each of the care (knowledge) domains. The same principle applies to the repetition of the attitudinal questions at the individual and group (sociological) level. Person-centredness demands that the patient's views are paramount plus the aggregated responses of the group as a whole.

Perhaps there is a 'drug TIME' too, which operates across all the domains once more, and each variously weighted objectively and subjectively? The concept of control and assessment of control is also critical.

I've placed GP decision-making across both 'individual' domains described as it is as a 'process' and for the patient as 'bedside manner', as also reflected in the GP and healthcare professional's communication with the family.

Clinical effectiveness and observations are likewise span the interpersonal and sciences domains. This is to denote the need to achieve and sustain parity of esteem and integrate physical and mental health care - pastoral and spiritual also.

'Cost' is anchored in the political domain, but clearly there are much wider economic ramifications, both in quality of life, quality of death and the way 'cost' is determined, measured, analysed, evaluated and reported.

For me nursing, medicine, healthcare are most effective when they are anticipatory. Observation, reflection and critical thinking are key. In a way for an individual to be health literate is a preparation for self-care. Although clearly in a general sense of health and well-being; not necessarily being literate with respect to a long-term medical condition.

Hodges' model is an idealisation and the detail is obviously described in the papers listed. The intention below is for readers to gain an appreciation of anticipatory prescribing and the application and scope of Hodges' model.

 Taking a larger perspective anticipatory prescribing is part of anticipatory care.

@GeriSoc https://twitter.com/GeriSoc/status/1374716732120645632?s=20

individual

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INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

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group

Anticipatory Prescribing Reassurance for patient, family &  friends clinical effectiveness subjective TIME observation agitation, distress (mood, anxiety, orientation, communication, identity - self, fear, understanding, mental capacity...) The patient's spiritual well-being needs are met*. 1. What is current practice? 2. What are the attitudes of patients? 3. What are the attitudes of family carers? 4. What are the attitudes of community healthcare professionals? [as individuals] GPs’ discussion with patients (Advanced care planning - choices) 5. What is its impact on patient comfort and symptom control?

Anticipatory Prescribing Physical access to medication and treatment is assured. clinical effectiveness objective TIME observation remote anticipatory prescribing increased 24 hours availability (out-of-hours) The intervention seeks to improve [my] symptom control pain, nausea and vomiting, agitation, and respiratory secretions. The Covid-19 pandemic has accelerated the practice of Anticipatory Prescribing; more terminally ill patients are having end-of-life care at home and in care homes. 1. What is current practice? New routes of administration injection, oral, sublingual, or rectal 5. What is its impact on patient comfort and symptom control? GPs’ decision-making processes Research: Systematic review and narrative synthesis Semi-structured interviews Web-based survey

An important intervention in supporting patients and families who wish to have last days of life care at home. 1. What is current practice? 2. What are the attitudes of patients? 3. What are the attitudes of family carers? 4. What are the attitudes of community healthcare professionals? [collectively] 5. What is its impact on patient comfort and symptom control? Patient and families’ well-being throughout the end-of-life journey *There is concord and respect regards patient's spiritual well-being needs. GPs’ discussion with family family caregiver administration

The Independent Review of the Liverpool Care Pathway found that the use of Anticipatory Prescribing without adequate explanation or justification led to families being concerned about over-sedation and the medication hastening death. 1. What is current practice? 5. What is its impact on patient comfort and symptom control? 6. Is it cost-effective? Revise pharmaceutical regulations to permit repurposing of anticipatory prescribing medications in care homes, wider community drug access, and recycling unused medications returned to pharmacies. Address stock shortages.

Bowers B, Ryan R, Kuhn I, Barclay S (2019) Anticipatory prescribing of injectable medications for adults at the end of life in the community: A systematic literature review and narrative synthesis. Palliative Medicine 33(2): 160-177 https://doi.org/10.1177/0269216318815796

Antunes B, Bowers B, Winterburn I, Kelly MP, Brodrick R, Pollock K, Majumder M, Spathis A, Lawrie I, George R, Ryan R, Barclay S. (2020) Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey. BMJ Supportive & Palliative Care; http://dx.doi.org/10.1136/bmjspcare-2020-002394

Bowers B, Barclay SS, Pollock K, Barclay S (2020) General Practitioners’ decisions about prescribing end-of-life anticipatory medications: a qualitative study. British Journal of General Practice; 70(699) e731-739 https://doi.org/10.3399/bjgp20X712625 

 

BBC Radio 4: "We need to talk ... "

individual

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INTERPERSONAL : SCIENCES

humanistic -------------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

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group-population

We  (Well, there's an 'i' in humanity..?)	Need
to Talk	Ab-out

Death

BBC Radio 4: We Need to Talk About Death

"Making legal advice a clinical department" Dept of Clinical Law

individual

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INTERPERSONAL : SCIENCES

humanistic -------------------------------------------  mechanistic

SOCIOLOGY : POLITICAL

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group-population

	Definitions: Child in England and Wales < 18 years of age
"Changing views in society have pushed...	"Making legal advice a clinical department"  'child' : 'adult' mental capacity, deprivation of liberty, candidness and forethought, end of life decisions, treating physical illness in the mental ill, consent, confidentiality and treatment refusals (p.20) ... legal considerations of patient rights to  the front of clinician's agendas"

Wheeler, R., & Marsh, M. (2016). Making legal advice a clinical department. Health Service Journal, April 13, 126: 6482, 20-21.

The Quantified Self that needs to be Qualified* (by definition)

H E A L T C A R E E R	Health-Life-Death Legacies Death End of Life Care Long-Term Chronic (Mental) Health Problems Support Groups 3rd Sector Acute Health Problems - Hospital [ Primary Care Consultations iterations Accidents - Emergency Dept ] Family/Self-Treated Complaints / Illnesses 'cuts and scrapes' Birth Conception ... Epigenetics	L I F E C H A N C E S
Public (Mental) Health

Where is the quantified self?
Where is health & well-being?
Aggregated data vs Aggregated experiences?
Public (mental) health: why so ungainly?
This rendering: service-centered vs person-centered.

Life chances and Health career are central to Hodges' model

*assuming health care services are available.

and : or

*assuming health literacy / education is enabled.

End of Life Care: Gold Standards Framework (Heaven's door)

INTERPERSONAL : SCIENCES
humanistic ------------------------------------------- mechanistic
SOCIOLOGY : POLITICAL

individual

PRIMARY CARE	ACUTE CARE
CARE HOMES	DEMENTIA (CARE)

group - population

Looking at a table 'GOLD STANDARDS SET BY BENCHMARK PROGRAMME' (p.23) in Prof. Thomas's HSJ article, I could see an instant fit between the four listed care contexts and the domains of Hodges' model.

There are also many overlaps and of course Hodges' model is an idealised resource. For example,  governance applies across all the above and in that way all can be placed in the POLITICAL domain.

Further points explaining the above includes:

• The GP and primary care seeing the person first not the diagnosis. Again in this sense - respect and dignity we can place all these care specialisms in the INTERPERSONAL. You would hope that primary care 'know' the patient as a person, an individual; or at least through recourse to the primary care record.
• If a care home 'works' it will be able to deliver care almost transparently, it is not a process but a social gathering. It is not the person's home (their home is not something to be forgotten, replaced like their past), but it seeks to emulate this as far as possible. Care is a routine that is also personalised and even at the end of life there is peace, calm and dignity.
• Dementia care is a political challenge, a priority and challenge across all the domains. As in the previous post - what training is provided to Health Care Assistants and other staff? How is the strategy for dementia progressing across all these care environments?

The National Gold Standards Framework Centre in End of Life Care

Thomas, K. (2014) 'End of life care is a litmus test for the whole of the NHS'.  HSJ, 31 January, 124, 6384, 21-23.

a reflection on relaxation or ...?

INTERPERSONAL : SCIENCES
humanistic ------------------------------------- mechanistic
SOCIOLOGY : POLITICAL

individual

group - population

Quotation Search:
http://www.quotationspage.com/search.php3?homesearch=lying+down&startsearch=Search

End of Life Care (Pathways), Nursing and Thresholds

There is a controversy (was in Telegraph) that has been growing for some time, concerning the Liverpool Care Pathway for end of life care. This is a very demanding and yet rewarding aspect of nursing. I have experience of end of life nursing care in a non-specialist capacity, having worked on wards for older adults and being involved with people who have mental health and life-threatening physical health problems.

It pains me greatly not just as a scouser that something with 'Liverpool' in it should become a cause of distress, a center for debate and review. Is the pathway green and shady? Is it comprised of stepping stones, with room for two, and with time granted for your next step? Or is there a danger in some instances the path can become tarmac clad, without the succor of a services stop for basic sustenance? Can a pathway become a motorway? What does that sign say? "DON'T HOG THE MIDDLE LANE!"

What pains me seriously is that what can be a invaluable, evidenced based palliative care resource can be undermined due to the complexity of the generic and palliative care situation.

If we truly practice person-centered care then there are no care pathways.

Or, to put it another way: there are as many care pathways as there are patients and carers.

Whether you believe in social medicine, or private; whether you are laissez-faire, or leave such matters to a higher power there is no escaping the need for organisation - for order.

The mix and concentration of people, knowledge, resources and time dictates that tasks, roles and processes be delineated and assigned. We need to assure a given level of quality, and to predict things, not everything is as difficult as the weather: or death. Pathways can assist in specific contexts.

Is there scope for personalisation on a pathway? ...

Steps and pace can vary and to the left and right of center. There are many pathways though: some valid - evidenced, award winning; while others might be broad, narrow, twisted - to become a disorientating ethical loop...

Being placed on a pathway denotes a decision point, a threshold. We need to remember in all fields of health and social care practice that there are multiple thresholds to be taken into account, communicated effectively and revisited:

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

'me' - existence, resilience, assets, personhood, ethics, personal values, mood, personalised care, understanding of treatment, communication skills, self-expression, loss, orientation, observation, distress, psychological assessment, sedation, beliefs, choices, :theology PURPOSE	'me' - existence, feeding, nutrition, fluids,  evidence base, Liverpool care pathway, quality of life measures, referral thresholds, prediction, resilience, reductive - holistic assessment, medication, distance, where: home-hospital-hospice? pain management, decision locale, specialism, basic nursing care, resilience PROCESS
memories, good-byes, love, compassion, carer under stress, reassurance, counselling skills, meetings with family, empathy and rapport, patient and relative engagement, life history, relative's recognition that loved one is dying, care strategies,  patient experts, patient - carer experience, communities of PRACTICE	consent, advocacy, mental capacity,  integrated working, effectiveness, independent autonomy, service access, bed availability, health & nursing in the media, scope of nursing, scope of medicine, law, medicolegal issues, whistleblowing, complaints, formal review, appeals, organisation, argumentation, professionalism, ageism, POLICY (re-PURPOSED)

The relative position of concepts above does not indicate priority.

"The LCP is not the answer to all our needs for care of the dying but is a step in the right direction."

Marie Curie Palliative Care Institute
Liverpool Care Pathway for the Dying Patient (LCP)