Chapter 9 - caring for someone in their last days of life

Question 1

what are the signs of a patient who is actively dying?

Answer 1

changes in skin colour
cool extremities
not eating or drinking
little or no swallow reflex
agitation and restlessness
change in continence 
cheyne stokes

Question 2

what are the five priorities of caring for a dying person?

Answer 2

1) recognise - that the patient is dying
2) communicate - effectively with the person who is dying and those important to them
3) involve - the dying person and those identified as important to them as much as they want to be involved in the decision making and care
4) support - the needs of families and others identified as important to the dying person and ensure they are actively explored, respected and met
5) create an individual care plan - for the persons physical, emotional, spiritual, psychological, cultural, and religious needs, including symptom management

Question 3

what are the most common physical needs of a patient in the last 48hrs of life?

Answer 3

noisy, moist breathing
pain
restlessness/agitation
breathlessness
nausea/vomiting

Question 4

what is given for secretions in EOL?

Answer 4

glycopyrronium bromide 0.6-1.2mg/24hrs in CSCI

or hyoscine butyl bromide 20mg-60mg/24hrs CSCI

or hyoscine hydrobromide 0.6-2.4mg/24hrs CSCI

Question 5

what are some non-pharmacological measures for secretions in EOL?

Answer 5

adequate positioning of the patient
reassurance to relatives
regular mouth care
suction - rarely necessary

Question 6

what can be given for agitation/restlessness in EOL?

Answer 6

midazolam 5-60mg/24hrs in CSCI

levomepromazine 25-100mg/24hrs CSCI

Question 7

what are some interventions for breathlessness in EOL?

Answer 7

nebuliser bronchodilators
O2
low dose opioids i.e. 5-10mg morphine/24hrs CSCI
midazolam SC 2.5-5mg hourly

Question 8

what are some non- pharmacological measures for breathlessness?

Answer 8

relaxation and diversion techniques
positioning - resting forwards
open windows
electric fan or hand held fan
massage

Question 9

what can be given for nausea at EOL?

Answer 9

antiemetic in a CSCI
if fails - consider PPI, rantidine or octreotide to reduce gastric secretions
if that measures, rarely an NG tube can be considered

Question 10

what are some indications for a CSCI?

Answer 10

intractable vomiting
severe dysphagia 
patient too weak to swallow oral drugs 
decreased consciousness level
poor alimentary absorption (rare)

Question 11

what areas should be avoided when siting a CSCI?

Answer 11

oedematous/lymphoedematous limbs
bony prominences
broken skin
irradiated site
skin folds, joints, waistband area

Question 12

if there is inflammation at the site of a CSCI, how can that be overcome?

Answer 12

diluting the drugs with more water
changing the site more often
using a plastic cannula 
adding dexamethasone 0.5mg to the contents of the syringe
apply hydrocortisone to the area

Question 13

what drugs are not compatible with water for injection as a diluent for CSCI?

Answer 13

diclofenac 
ketamine 
methadone 
ondansetron 
ketorolac

Question 14

what drug is not compatible with NaCL?

Answer 14

cyclizine

Question 15

what drugs are NOT suitable for SC use?

Answer 15

chlorpromazine
diazepam
pro chlorpromazine

Question 16

what drugs need a CSCI alone?

Answer 16

dexamethasone (unless using less than 1mg)
diclofenac
ketamine 
ketorolac
parecoxib
phenobarbital

Question 17

what does care after death involve?

Answer 17

honouring cultural/spiritual wishes of the patient
prepare body for transfer to the morturary
offering family opportunity to participate in this process if they want to
ensuring privacy and dignity of the deceased person is maintained
ensuring health of everyone that comes into contact with the body if protected
organ/tissue donation if they wished
return possessions to NOK

Question 18

when should a death be referred to the coroner?

Answer 18

cause unknown
suspicious or violent circumstances
accidental injury
industrial disease e.g. mesothelioma
neglect or self harm 
suicide
doctor not in attendance in last 14 days (?covid) 
Creutzfeldt-Jakob disease
prisoner or in state detention

Question 19

what are contraindications for tissue donation?

Answer 19

untreated systemic infection
AIDS/HIV
Hep A, B, C
alzheimers disease
disease of unknown aetiology
MND, parkinsons, MS, ME, CJD
cancer - however can donate cornea's

Question 20

why is systemic corticosteroid use prior to death an potential issue for organ donation?

Answer 20

a dose greater than 30mg pred a day can mask presence of infection/inflammation and therefore if patients have been taking such doses for more than 2 weeks in the last 6 months prior to death, this should be discussed with the transplant coorindator

Question 21

how quickly should corneas be retrieved in organ donation?

Answer 21

within 24 hours

Question 22

how quickly must bone and tendons be retrieved for organ donation?

Answer 22

within 7 hours

Question 23

how quickly must heart valves be retrieved?

Answer 23

48 hours

Question 24

how

Question 25

how quickly must skin be retrieved in organ donation?

Answer 25

48 hours