Chapter 9 - caring for someone in their last days of life Flashcards
what are the signs of a patient who is actively dying?
changes in skin colour cool extremities not eating or drinking little or no swallow reflex agitation and restlessness change in continence cheyne stokes
what are the five priorities of caring for a dying person?
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
what are the most common physical needs of a patient in the last 48hrs of life?
noisy, moist breathing pain restlessness/agitation breathlessness nausea/vomiting
what is given for secretions in EOL?
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
what are some non-pharmacological measures for secretions in EOL?
adequate positioning of the patient
reassurance to relatives
regular mouth care
suction - rarely necessary
what can be given for agitation/restlessness in EOL?
midazolam 5-60mg/24hrs in CSCI
levomepromazine 25-100mg/24hrs CSCI
what are some interventions for breathlessness in EOL?
nebuliser bronchodilators
O2
low dose opioids i.e. 5-10mg morphine/24hrs CSCI
midazolam SC 2.5-5mg hourly
what are some non- pharmacological measures for breathlessness?
relaxation and diversion techniques positioning - resting forwards open windows electric fan or hand held fan massage
what can be given for nausea at EOL?
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
what are some indications for a CSCI?
intractable vomiting severe dysphagia patient too weak to swallow oral drugs decreased consciousness level poor alimentary absorption (rare)
what areas should be avoided when siting a CSCI?
oedematous/lymphoedematous limbs bony prominences broken skin irradiated site skin folds, joints, waistband area
if there is inflammation at the site of a CSCI, how can that be overcome?
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
what drugs are not compatible with water for injection as a diluent for CSCI?
diclofenac ketamine methadone ondansetron ketorolac
what drug is not compatible with NaCL?
cyclizine
what drugs are NOT suitable for SC use?
chlorpromazine
diazepam
pro chlorpromazine
what drugs need a CSCI alone?
dexamethasone (unless using less than 1mg) diclofenac ketamine ketorolac parecoxib phenobarbital
what does care after death involve?
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
when should a death be referred to the coroner?
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
what are contraindications for tissue donation?
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
why is systemic corticosteroid use prior to death an potential issue for organ donation?
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
how quickly should corneas be retrieved in organ donation?
within 24 hours
how quickly must bone and tendons be retrieved for organ donation?
within 7 hours
how quickly must heart valves be retrieved?
48 hours
how
how quickly must skin be retrieved in organ donation?
48 hours
