Clinical Skills - Death Flashcards
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
What are frail pts at increased risks of
Decline as a result of illness or stressors such as surgery
How many people 85+ are potentially living with frailty
85%
Proportion of 65+ population living with severe frailty
3%
Proportion of those 65+ with moderate frailty
12%
Proportion of those 65+ with mild frailty
35%
Why is frailty difficult to identify at an early stage
Develops slowly over 5-10 years
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
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?
Using PRISMA-7 score
A score of 3 or more indicateds frailty
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
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
When do we need to consider deprescribing in elderly
When frailty is recognised
Comorbvidities cause pts to steadily accumulate mediations
Drugs left on medication list for elderly should …?
Be justified
Not be causing s/e
Be easy for the pt to manage
STOPP START tool
Medication review tool
Screening Tool of Older People’s Potentially Inappropriate Prescriptiona
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
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
Special considerations at the EoL
Recognising the terminal phase Fears and prejudices Symptom control Dignity Consideration for relatives etc Communication
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
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
Common symptoms of death
Profound weakness Gaunt appearance Drowsiness Disorientation Diminished oral intake Poor concentration Skin colour changes Temp changes at extremities
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
Aims of treatment of death
Prolongation/ shortening
Symptom control
Medical treatment of dying
Symptoms
Problems with medications
How we manage the symptoms
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
