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MBBS - Year 1 > Clinical Skills - Death > Flashcards

Clinical Skills - Death Flashcards

1
Q

Frailty or age-related physical debility

A

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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2
Q

What are frail pts at increased risks of

A

Decline as a result of illness or stressors such as surgery

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3
Q

How many people 85+ are potentially living with frailty

A

85%

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4
Q

Proportion of 65+ population living with severe frailty

A

3%

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5
Q

Proportion of those 65+ with moderate frailty

A

12%

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6
Q

Proportion of those 65+ with mild frailty

A

35%

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7
Q

Why is frailty difficult to identify at an early stage

A

Develops slowly over 5-10 years

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8
Q

Assessing for frailty

A

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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9
Q

PRISMA-7 questions

A
  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?
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10
Q

Using PRISMA-7 score

A

A score of 3 or more indicateds frailty

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11
Q

Gait speed test

A

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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12
Q

Physiological changes in the elderly —> frailty

A

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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13
Q

When do we need to consider deprescribing in elderly

A

When frailty is recognised

Comorbvidities cause pts to steadily accumulate mediations

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14
Q

Drugs left on medication list for elderly should …?

A

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

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15
Q

STOPP START tool

A

Medication review tool

Screening Tool of Older People’s Potentially Inappropriate Prescriptiona

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16
Q

What might improving QoL incl

A

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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17
Q

NICE Clinical guideline 56

A

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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18
Q

Special considerations at the EoL

A 
Recognising the terminal phase 
Fears and prejudices 
Symptom control 
Dignity 
Consideration for relatives etc 
Communication
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19
Q

Why is managing death different to managing other conditions

A

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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20
Q

Management of death vs diseases

A 
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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21
Q

Common symptoms of death

A 
Profound weakness 
Gaunt appearance 
Drowsiness 
Disorientation 
Diminished oral intake 
Poor concentration 
Skin colour changes 
Temp changes at extremities
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22
Q

Vital detour of death

A

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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23
Q

Aims of treatment of death

A

Prolongation/ shortening

Symptom control

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24
Q

Medical treatment of dying

A

Symptoms
Problems with medications
How we manage the symptoms

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25
Q

Symptoms of dying that can be managed medically

A

Pain
Breathlessness
Agitation
Secretions

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26
Q

Secretions that need to managed during death

A

Vomiting
Fitting / seizures
Bleeds
Urinary incontinence/ retentions

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27
Q

Issues with managing symptoms of death

A

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

28
Q

Problems with drugs at EoL

A

Sedation
Respiratory depression
‘Drying’
Confusion/ amnesia

29
Q

Doctrine of double effect

A

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

30
Q

Exa,mples of double effect

A

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

31
Q

Essentials of death symptom control

A

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

32
Q

Drugs for pain and EoL

A

Opioids (route of delivery)- benefits outweigh problems

Dose dependent on need

33
Q

Drugs given for pain at EoL

A

Diamorphine
Morphine
Oxycodone
Fentanyl

34
Q

Managing breathlessness in

pt’s at EoL

A

Oxygen – poorly managed by pt’s
Opioids
Benzodiazepines

35
Q

Managing agitation in EoL pt’s

A

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

36
Q

Drugs for agitation

A

Midazolam
Haloperidol
Levomepromazine

37
Q

Midazolam dosage

A

2.5 - 10mg prn

38
Q

Midozolam

A

Sedative, anxiolytic, amnesic

39
Q

Haloperidol

A

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

40
Q

Haloperidol dosage

A

1.5 - 5 mg prn

41
Q

The death rattle

A

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

42
Q

What causes the death rattle

A

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

43
Q

When can the death rattle be v distressing to relatives

A

If combined with Cheynes-Stokes breathings

44
Q

Managing secretions secretions at EoL

A

Positions
Suction
Drugs
Syringe driver

45
Q

Drugs for secretion

A

Hyoscine butylbromide
Hyoscine hydrobromide
Glycopyrrhonium

46
Q

Anticipatory medications for EoL

A 
At least one parenteral of each on the drug chart 
Analgesic
Anti-emetic 
Sedative 
Anti – secretory
47
Q

Syringe drivers

A

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

48
Q

CSCI

A

Continuous subcutaneous infusion

49
Q

Advantages of syringe drivers

A

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

50
Q

Liverpool Care Pathways

A

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

51
Q

Main concerns with Liverpool Care Pathway

A

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

52
Q

New priorities for care - LCP

A

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

53
Q

What is care given in EoL based on and tailored to

A

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

54
Q

What does care given in EoL incl

A

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

55
Q

What does care given in EoL involve

A

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

56
Q

Important considerations in EoL

A

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

57
Q

NICE guidance on EoL

A

Care of dying adults in the last days of life

  • Clinical guideline NG31
  • Methods, evidence, and recommendations
  • 2015, revised 2016
  • Individual care plans
58
Q

Challenges for delivering EoL care

A

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?

59
Q

GSF

A

Gold Standard Framework - prognostic tool

Red - last days of life
Amber - weeks prognosis
Green - months

60
Q

Cheyne-Stokes

A

Erratic breathing pattern

61
Q

What are anticholinergics used for

A

Secretions e.g. hyoscine

62
Q

Verifying death

A 
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
63
Q

Assessing pt’s response to pain - verifying death

A

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

64
Q

Assessing pt’s pupillary reflexes - verifying death

A

Use a pen torch

After death, pupils becomes fixed and dilated

65
Q

Auscultation when verifying death

A

Listen to heart sounds for at least 2 minutes

Listen for respiratory sounds for ta least v3 minutes

MBBS - Year 1 (93 decks)

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