Discuss the recognition and management of a dying patient

Question 1

What 4 drugs may be prescribed to control pain in a dying patient?

Answer 1

1. diamorphine (heroin)
2. morphine
3. oxycodone
4. fentanyl

Question 2

How do you manage a dying patient with agitation?

Answer 2

• treat in a calm atmosphere with light
• familiar faces
• reorientate
• sedate only if necessary

Question 3

What is the death rattle often combined with?

Answer 3

Cheynes-stokes breathing and secretions

Question 4

What 4 anticipatory medicines should always be written on a dying patient’s drug chart?

Answer 4

1. analgesic
2. anti-emetic
3. sedative
4. anti-secretory

Question 5

As the common symptoms of dying are relatively general, what else must be true to recognise that this patient is dying?

Answer 5

The patient MUST have a condition that would mean it is not surprising that the patient is dying

(this includes old age)

Question 6

What underlying, treatable conditions can cause agitation in the dying patient?

Answer 6

• UTI
• urinary retention

Question 7

What are 7 common symptoms of a dying patient that are not medically managed?

Answer 7

1. profound weakness
2. drowsiness
3. disorientation
4. diminished oral intake
5. poor concentration
6. skin colour changes
7. temperature changes at extremities

Question 8

What are 4 issues regarding the treatment of a dying patient?

Answer 8

1. the burden of drugs vs. control of symptoms
2. side effects of drugs
3. uncertainty of prognosis (eg. should we continue life-prolonging drugs such as antibiotics)
4. route of delivery (oral route not really an option)

Question 9

True or false?

A dry mouth in a dying patient can be treated with mouth care and a drip of parenteral fluids

Answer 9

False

Only mouth care is effective

Question 10

What is the death rattle and what causes it?

Answer 10

• a noisy, ‘rattly’, wet breathing noise
• normal secretions that a dying patient is too weak to clear

Question 11

What is Cheynes-stokes breathing?

Answer 11

• Pattern of breathing:
• involving a fast, shallow breathing,
• followed by slow heavier breathing,
• and moments without any breath at all (apnea).

Question 12

What 3 drugs can treat secretions, and what is used to deliver them?

Answer 12

1. Hyoscine butylbromide
2. Hyoscine hydrobromide
3. Glycopyrrhonium

Infusion with a syringe driver

Question 13

What are the disadvantages of treating secretions in a dying patient with suction?

Answer 13

• it is very interventional
• can only be done in a hospital (no equipment at home)

Question 14

Why are non-oral routes used for delivering medication to dying patients?

Answer 14

• They are not alert enough to receive drugs
• They have dry mouths and struggle to swallow
• They are not eating

Question 15

True or false?

In the last few days of life we manage breathlessness by finding the cause and treating this

Answer 15

False

prior to the last few days of life this would be true

Question 16

What is the doctrine of the double effect?

Answer 16

• If doing something morally good has a morally bad side effect,
• it is ethically okay to do it
• providing the bad side-effect was not intended
• this is true, even if you foresaw that the bad effect would probably happen

Question 17

What does “anticipation of problems” refer to when treating a dying patient?

Answer 17

thinking ahead and adding drugs “as required” to the drug chart for symptoms we know will occur, even if they are not present at the moment

Question 18

What are 3 key essentials of pharmacological symptom control?

Answer 18

1. a non-oral route
2. anticipation of problems
3. stop medication that is not helping symptoms

Question 19

How do we manage pain in dying patients?

Answer 19

• opioids, dose dependent on need

Question 20

True or false?

“It is perfectly acceptable to stop oxygen if you are fairly certain that the patient is in their last days of life”

Why?

Answer 20

True

Oxygen is often intolerated in the last days of life (patients often push away the mask or nasal tongs)

Question 21

What drugs can we use to reduce the feelings of breathlessness if it is not feasible to address the cause?

Answer 21

• opioids
• benzodiazepines

Question 22

What 3 drugs can be used to treat an agitated dying patient?

And why should you try to avoid treating agitation with drugs, if possible?

Answer 22

1. Midazolam (sedative, anxiolytic, amnesic)
2. Haloperidol (antipsychotic)
3. Levomepromazine

these drugs can paradoxically worsen agitation

Question 23

What is one of the most distressing symptoms for a patient?

Answer 23

Dry mouth

Question 24

What is a syringe driver?

Answer 24

a device that administers medicines subcutaneously over a period of time