Respiratory Sepsis in Advanced Dementia

Case study submission for the  College of Paramedics Carol Furber Award 2017

Respiratory Sepsis in Advanced Dementia 

Patient details changed to maintain confidentiality 
Written March 2017, published online November 2017

Case

An ambulance was called to a residential nursing home for a 78-year-old male with difficulty in breathing. `Stanley` was found curled in the foetal position in his bed with obvious respiratory distress. 

The patient’s wife and daughter were with him and, in conjunction with the nursing home staff, explained Stanley had poor baseline health and recurrent chest infections. On this occasion, his breathing had deteriorated over several days before the out-of-hours GP had recommended an ambulance be called.

Initial assessment revealed

Airway Patent, dry

Breathing Respiratory rate = 28 Oxygen saturations = 85% on air, Increased work of breathing with accessory muscle use, Coarse rales, especially on the left sided lobes,Feeble but productive cough; yellow sputum

Circulation Heart rate = 122 in sinus tachycardia, Blood pressure = 98/50, Regular radial pulse, Warm peripheries

Disability Glasgow Coma Score = 8/15 (2,2,4); this was not acutely worsened from Stanley’s baseline Blood sugar = 8.3, Moaning and grimacing in apparent pain

Examination o Temperature = 38.80C, Dry skin and mucosa

Allergies None stated

Medications Morphine and midazolam (in `just in case` box; never previously used), Ventolin 

Past Medical History Dementia, Frailty

Social History Permanent resident in nursing home. Dependent on carers for all daily activities, including feeding and personal care. No ability to meaningfully interact with other people, Clinical frailty score = 8 Wife and daughter live nearby and share valid Lasting Power of Attorney. Another daughter lived in another county. 

The patient was diagnosed with respiratory sepsis in the context of advanced dementia. After reviewing the situation with the ambulance crew, Stanley’s family did not feel admission was in his best interests. He was given a total of 7.5mg of subcutaneous morphine which reduced respiratory distress and alleviated the patient’s pained moans. The patient was also referred by telephone to a palliative care team, who agreed to visit the next day.

Several weeks later, a letter was received by the ambulance trust’s patient experience department which stated the patient lived for a further week, before dying in the nursing home surrounded by his family. They were grateful he had not been taken to hospital by the ambulance crew.

Discussion

The UK Sepsis Trust highlight there are 150,000 cases of sepsis each year, causing 44,000 deaths1. To reduce mortality and morbidity, both the mainstream media2 and professional literature3 endorse aggressive management of sepsis by healthcare professionals, including paramedics4. Standard treatment includes early recognition, supplemental oxygen, intravenous fluids, antibiotics, lactate analysis and urine measurement; collectively known as the `Sepsis Six`5. Some Sepsis Six procedures are commonly implemented by ambulance clinicians, whereas others are undertaken in the emergency department or ward. Additional treatments may include intensive care unit admission, renal filtration, and inotrope administration6. 

It is argued that by better treating sepsis, a medium sized general hospital could prevent 100 deaths and save £1.25million annually7. However, some of the interventions are known to be painful8, with significant side effects and limited efficacy in patients with severe co-morbidities where death due to terminal disease is inevitable. Overall, their use might not be in the patient’s best interests9.

The National Institute for Health and Care Excellence’s `guideline 51` has advice for recognising acute changes in mental status caused by infection, even when the patient has underlying dementia. The guideline recommends sepsis is actively treated, and a 999 ambulance “usually” called when diagnosed outside of the acute hospital setting10. 

Dementia itself is a terminal illness11. There are 850,000 people living with the condition in the UK12, and their symptoms progressively worsen until they are completely dependent carers for all activities of daily living and unable to interact with other people; a state known as `advanced dementia`13. From the onset of symptoms, survival rarely exceeds 10 years14 and many articles argue that dementia-related decline is undignified and unpleasant for the patient’s friends and family to experience15. 

The most common precipitating cause of dementia-related death is overwhelming respiratory infection, which is reported in 66% of fatalities. Studies have shown that it is possible to successfully treat respiratory infection in patients with advanced dementia, where the primary outcome measure is short-term extended lifespan, but treatment does not improve the patient’s quality of life, levels of comfort or long-term survival17. 

It is therefore argued in some end of life care literature that people with advanced dementia and severe respiratory infection may be best cared for with the alleviation of symptoms and a focus on comfort, rather than be admitted to hospital9. 

The UK Ambulance Services Clinical Practice Guidelines 2016 have a chapter on end of life care which endorse ambulance clinicians to “consider” alternative pathways and seek multidisciplinary advice to avoid unnecessary admission to the emergency department. Where interventions are required by the ambulance clinician, there is advice on a range of techniques to reduce suffering and appropriately facilitate natural death18. 

Stanley received morphine from the ambulance crew, which apparently reduced suffering and made his family less fearful for his welfare. A clinician discussed the situation was a local palliative care team, made an initial referral and developed an appropriate plan for further care that respected his family’s wishes and resulted in a more satisfactory experience of death. 

This case positively demonstrates the modern face of paramedic practice, where reasoned decisions and evidence-based care is provided by skilled and autonomous professionals in complex situations with competing treatment paradigms, rather than simply transporting patients approaching the end of their life to an emergency department at great inconvenience and discomfort, and at avoidable expense to the wider NHS.  

With high-profile campaigns relating to both dementia and sepsis raising public recognition and expectation, associated demands on NHS services may grow. The ambulance services may see ever more frequent calls to people like Stanley, and paramedics must continue to be appropriately supported to make complex medical decisions in situations where death is a real possibility, while alleviating pressure on busy emergency departments, but ultimately act in the patient’s best interests.

References

1. UK Sepsis Trust, Homepage, 2016, http://sepsistrust.org/
2. Daily Mail, 2015, http://www.dailymail.co.uk/news/article-3046312/Hospitals-failing-spotsilent-killer-Treating-sepsis-early-save-12-500-lives-year.html
3. Langley, M. & Langley, C., Journal of Paramedic Practice volume 4, issue 5, 2012, http://www.paramedicpractice.com/cgi-bin/go.pl/library/article.cgi?uid=91457
4. Ambulance Today, Doing the Best for Sepsis Patients, 2014, http://www.ambulancetoday.co.uk/news-item/doing-the-best-for-sepsis-patients/
5. UK Sepsis Trust, Sepsis Six, 2017, http://sepsistrust.org/wpcontent/uploads/2016/04/Black-Sepsis-6-Poster-Medical-2.jpg
6. Rhodes A et al., Surviving Sepsis Campaign: International Guidelines for Management for Sepsis and Septic Shock: 2016, Critical Care Medicine, 2016 http://journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___Int ernational.15.aspx
7. UK Sepsis Trust, Key recommendations, 2013, http://sepsistrust.org/wpcontent/uploads/2013/10/briefing.pdf
8. Bledsoe, B., Porter, R. & Cherry, R. Paramedic Care Principles and Practice Introduction to Advanced Prehospital Care, Intravenous Access and Medication Administration, 2006, Brady
9. Watson, M., Lucas, C., Hoy, A., Back, I. & Armstrong, P. Palliative Adult Network Guidelines, 2011, Mount Vernon Cancer Network
10. National Institute for Health and Care Excellence, NG51: Sepsis: recognition, diagnosis and early management, 2016, https://www.nice.org.uk/guidance/NG51
11. Alzheimer’s Society, End of life care, 2017, https://www.alzheimers.org.uk/info/20046/help_with_dementia_care/80/end_of_life_care/3
12. Alzheimer’s Society, Dementia UK report, 2017, https://www.alzheimers.org.uk/info/20025/policy_and_influencing/251/dementia_uk
13. Mitchell, S.L. Advanced Dementia, New England Journal of Medicine, 2015, http://www.nejm.org/doi/full/10.1056/NEJMcp1412652
14. Alzheimer’s Society, The later stages of dementia, 2017, https://www.alzheimers.org.uk/info/20073/how_dementia_progresses/103/the_later_stages _of_dementia/4
15. The Guardian, The raw horror of Alzheimer’s, 2010, https://www.theguardian.com/lifeandstyle/2010/jun/01/andrea-gillies-mother-in-lawalzheimers
16. Alzheimer’s Society, The later stages of dementia, 2017, https://www.alzheimers.org.uk/info/20073/how_dementia_progresses/103/the_later_stages _of_dementia/4
17. Givens, J. et al. Survival and Comfort After Treatment of Pneumonia in Advanced Dementia, Archives of Internal Medicine, 2012, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914628/
18. UK Ambulance Services Clinical Practice Guidelines 2016, Association of Ambulance Chief Executives