Death - Clinical medicine

Question 1

Name the tests including frailty scales GPs can use to assess for frailty

Answer 1

• eFl
• PEONY
• PRISMA-7
• QAdmissions
• Gait speed test

Question 2

What result of the gait speed test will bean indication of frailty?

Answer 2

An average gait speed of longer than 5 seconds to walk 4 metres is an indication of frailty

Question 3

Name the drugs that require special consideration in people over 65s and explain the reason why

Answer 3

Question 4

Name the common symptoms of death

Answer 4

• Profound weakness
• Gaunt appearence
• Drowsiness
• Disorientation
• Diminished oral intake
• Poor concentration
• Skin colour changes
• Temperature change at extremities

Question 5

As well as the symptoms of death, what is an important feature that a patient must have?

Answer 5

The patient must have a condition that would mean it is not surprising that the patient is dying e.g, end stage heart failure/metastic failure. This can include old age

Question 6

What factors are invoved in the medical treatment of dying

Answer 6

• Symptoms and managing them
• Problems with medications

Question 7

Name the symptoms of dying that must be managed medically

Answer 7

• Pain
• Breathlessness
• Agitation
• Secretions - vomiting, fitting/seizures/bleeds/urinary continence/retentions

Question 8

List the problems with drugs at end life

Answer 8

• Sedation
• Respiraory depression
• ‘Drying’
• Confusion/amnesia

Question 9

List the special considerations at the end of life

Answer 9

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

Question 10

What are the 3 essentials of symptom control in the dying

Answer 10

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

Question 11

How are existing drugs a patient is on controlled?

Answer 11

• Each drug left on chart should be justified
• Each drug should not be causing side effects
• Each drug should be easy for the patient to manage

Question 12

How is pain managed in a dying patient?

Answer 12

• Opiods (benefits outweighs risks)
• Diamorphine - morphine, oxycodone, fentanyl

Question 13

How is breathlessness managed in a dying patient?

Answer 13

• Oxygen
• Opiods
• Benzodiazepines

Question 14

How is agitation in a dying patient managed?

Answer 14

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

Drugs

• Midazolam 2.5-10mg prn - sedative, anxiolytic, amnesic
• Haloperidol 1.5-5mg prn - antipsychotic, helps settle confusion if this is the cause of agitation
• Levomepromazine

Question 15

What is the death rattle?

Answer 15

• Common
• A noisy, ‘rattly’, wet breathing noise
• Probably normal secretions that a dying patient is too weak to clear
• Upper airways
• Can sound like the patient is drowning
• If cominbined with Cheynes-Stokes breathing it can be very distressing

Question 16

Describe the managment of secretions of dyig patient

Answer 16

• Change positioning
• Suction
• Syringe driver - delivers steady infusion
• Dugs - hycosine butylbromide, hycosine hydrobromide, glycopyrrhonium

Question 17

Name the 4 anticipatory medications, that at least one should be written on the drug chart of a dying patient

Answer 17

• Analgesic
• Anti-emetic
• Sedative
• Anti-secreatory

Question 18

a) What is a syringe driver
b) What are the advantages of using a syringe driver?

Answer 18

a) A device for delivering a steady infusion. In palliatice care it is usually S/C

b)

• Less need for repeated injections
• Maintains a constant plasma level
• Control multiple symptoms - combination of drugs
• Increased independance and mobility (potential)
• Reloading once a day