1. Are you older than 85? 2. Are you male? 3. In general, do you have any health problems that require you to limit your activities? 4. Do you need someone to help you on a regular basis? 5. In general, do you have any health problems that require you to stay at home? 6. In case of need can you count on someone close to you? 7. Do you regularly use a stick, walker, or wheelchair to get about?

Clinical Skills - Death Flashcards by Jasmine Sappor

Frailty or age-related physical debility

An age-related, multi-dimensional state of decreased physiological reserves
Not an illness, combines effects of aging w/ multiple long-term condns

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What are frail pts at increased risks of

Decline as a result of illness or stressors such as surgery

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How many people 85+ are potentially living with frailty

85%

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Proportion of 65+ population living with severe frailty

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Proportion of those 65+ with moderate frailty

12%

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Proportion of those 65+ with mild frailty

35%

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Why is frailty difficult to identify at an early stage

Develops slowly over 5-10 years

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Assessing for frailty

GP records may be using with validates clinical frailty scales
These incl eFL, PEONY, PRIMSA-7, or QAdmissions
Gait speed test can indicate frailty

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PRISMA-7 questions

Are you older than 85?
Are you male?
In general, do you have any health problems that require you to limit your activities?
Do you need someone to help you on a regular basis?
In general, do you have any health problems that require you to stay at home?
In case of need can you count on someone close to you?
Do you regularly use a stick, walker, or wheelchair to get about?

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Using PRISMA-7 score

A score of 3 or more indicateds frailty

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Gait speed test

An avg gait speed of longer than 5 seconds to walk 4m is an indication of frailty
Usually repeated 3x, allowing adequate time for recovery between each attempt

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Physiological changes in the elderly —> frailty

Changes in body composition with loss of lean body mass
Loss of muscle strength and poor balance
Decline in renal function
Changes in metabolism of drugs cleared by the liver

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When do we need to consider deprescribing in elderly

When frailty is recognised

Comorbvidities cause pts to steadily accumulate mediations

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Drugs left on medication list for elderly should …?

Be justified
Not be causing s/e
Be easy for the pt to manage

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STOPP START tool

Medication review tool

Screening Tool of Older People’s Potentially Inappropriate Prescriptiona

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What might improving QoL incl

Reducing treatment burden and optimising care and support by identifying ways of maximising benefit from exiting treatments and treatments that could be stopped because of limited benefit

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NICE Clinical guideline 56

Treatments and follow-up arrangements with a high burden
Medicines with a higher risk of adverse events e.g., falls, GI bleeding, AKI
Non-pharmacological treatments as possible alternatives to some medicines
Alternative arrangements for follow-up to coordinate or optimise the number of appointments

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Special considerations at the EoL

Recognising the terminal phase 
Fears and prejudices 
Symptom control 
Dignity 
Consideration for relatives etc 
Communication

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Why is managing death different to managing other conditions

Due to fears and prejudices - both our own, those of patients, those of relatives and those of others, including the media

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Management of death vs diseases

You only get one chance 
Managing relatives
Self-fulfilling prophecy - potentially how you manage the deterioration in a patient’s condition could lead them to die
Emotions can run high 
Public perception 
Ethics and religion

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Common symptoms of death

Profound weakness 
Gaunt appearance 
Drowsiness 
Disorientation 
Diminished oral intake 
Poor concentration 
Skin colour changes 
Temp changes at extremities

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Vital detour of death

The pt MUST have a condn that would mean it is not surprising that the pt is dying e.g., end stage heart failure/ metastatic failure. This can incl old age

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Aims of treatment of death

Prolongation/ shortening

Symptom control

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Medical treatment of dying

Symptoms
Problems with medications
How we manage the symptoms

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Symptoms of dying that can be managed medically

Pain Breathlessness Agitation Secretions

Secretions that need to managed during death

Vomiting Fitting / seizures Bleeds Urinary incontinence/ retentions

Issues with managing symptoms of death

Burden of drugs vs control of symptoms Side effects of drugs Uncertainty of prognosis Route of delivery – oral route nor an option

Problems with drugs at EoL

Sedation Respiratory depression ‘Drying’ Confusion/ amnesia

Doctrine of double effect

If doing something morally good has a morally bad s/e it is ethically OK to do it providing the bad s/e was not intended. This is true even if you foresaw that the bad effect would probably happen

Exa,mples of double effect

Morphine - feduces respiratory rate, sedated and may hasten death but helps reduce pain

Essentials of death symptom control

Non-oral route Anticipation of problems – drugs added to ‘as required’ section of drug chart Stop medication not helping symptoms

Drugs for pain and EoL

Opioids (route of delivery)- benefits outweigh problems | Dose dependent on need

Drugs given for pain at EoL

Diamorphine Morphine Oxycodone Fentanyl

Managing breathlessness in | pt's at EoL

Oxygen – poorly managed by pt’s Opioids Benzodiazepines

Managing agitation in EoL pt's

Exclude treatable causes – e.g., UTI, urinary retention Treat in a calm atmosphere with light – e.g., side room Familiar faces Re-orientate Sedate only if necessary

Drugs for agitation

Midazolam Haloperidol Levomepromazine

Midazolam dosage

2.5 - 10mg prn

Midozolam

Sedative, anxiolytic, amnesic

Haloperidol

Antipsychotic, so helps settle confusion if this is cause of agitation

Haloperidol dosage

1.5 - 5 mg prn

The death rattle

Common A noisy, ‘rattly’, wet breathing noise Upper airways Can sound like the pt is drowning

What causes the death rattle

Probably normal secretions that a dying pt is too weak to clear

When can the death rattle be v distressing to relatives

If combined with Cheynes-Stokes breathings

Managing secretions secretions at EoL

Positions Suction Drugs Syringe driver

Drugs for secretion

Hyoscine butylbromide Hyoscine hydrobromide Glycopyrrhonium

Anticipatory medications for EoL

``` At least one parenteral of each on the drug chart Analgesic Anti-emetic Sedative Anti – secretory ```

Syringe drivers

A device for delivering a steady infusion In palliative care usually sub-cutaneous CSCI

CSCI

Continuous subcutaneous infusion

Advantages of syringe drivers

Less need for repeated injections/comfort Maintains constant plasma levels Control multiple symptoms – combi of drugs Increased independence and mobility (potential) Reloading once in a day

Liverpool Care Pathways

An integrated Care Pathway Well established – developed in late 1990’s A tool to prompt care – idea was to bring non-specialist places of care to the standard of hospices as the vast majority of people do not die in a hospice

Main concerns with Liverpool Care Pathway

Correctly recognising pt was dying Unduly sedation Hydration and some essential meds may have been withheld or withdrawn,

New priorities for care - LCP

Possibility of soon death recognised and communicated clearly Communication between staff, pt and those close to them Pt and close ones involved in decisions Listen to those close to pt Individualise care plan

What is care given in EoL based on and tailored to

The needs, wishes and preferences of the dying person and as appropriate, their family and health and those identified as important to them

What does care given in EoL incl

Regular and effective communication between the dying person and their family and health and care staff and between health and care staff themselves

What does care given in EoL involve

Assessment of the person’s condition whenever that condition changes and timely & appropriate reposes to these changes

Important considerations in EoL

The dying pt is still a person – treat with dignity and respect The family are very stressed and frightened – communicate exceptionally well Ethics and spirituality is at the forefront – embrace and work with other’s views

NICE guidance on EoL

Care of dying adults in the last days of life - Clinical guideline NG31 - Methods, evidence, and recommendations - 2015, revised 2016 - Individual care plans

Challenges for delivering EoL care

The ‘who’ and ‘how; of EOL Uncertainty of timescale Unpredictability of needs Loneliness of people affecting decision-making Carer fatigue Who is available to care at diff times?

GSF

Gold Standard Framework - prognostic tool Red - last days of life Amber - weeks prognosis Green - months

Cheyne-Stokes

Erratic breathing pattern

What are anticholinergics used for

Secretions e.g. hyoscine

Verifying death

``` Assess pt's repose to verbal stimuli Assess pt's response to pain Assess pt's pupillary reflex Palpate carotid artery for a pulse Perform auscultation in an. attempt tp identify any Hera or respiratory sounds ```

Assessing pt's response to pain - verifying death

Apply pressure to pt's fingernail Perform trapezius squeeze Apply supraorbital pressure

Assessing pt's pupillary reflexes - verifying death

Use a pen torch | After death, pupils becomes fixed and dilated

Auscultation when verifying death

Listen to heart sounds for at least 2 minutes | Listen for respiratory sounds for ta least v3 minutes