Discuss the recognition and management of a dying patient Flashcards
What 4 drugs may be prescribed to control pain in a dying patient?
- diamorphine (heroin)
- morphine
- oxycodone
- fentanyl
How do you manage a dying patient with agitation?
- treat in a calm atmosphere with light
- familiar faces
- reorientate
- sedate only if necessary
What is the death rattle often combined with?
Cheynes-stokes breathing and secretions
What 4 anticipatory medicines should always be written on a dying patient’s drug chart?
- analgesic
- anti-emetic
- sedative
- anti-secretory
As the common symptoms of dying are relatively general, what else must be true to recognise that this patient is dying?
The patient MUST have a condition that would mean it is not surprising that the patient is dying
(this includes old age)
What underlying, treatable conditions can cause agitation in the dying patient?
- UTI
- urinary retention
What are 7 common symptoms of a dying patient that are not medically managed?
- profound weakness
- drowsiness
- disorientation
- diminished oral intake
- poor concentration
- skin colour changes
- temperature changes at extremities
What are 4 issues regarding the treatment of a dying patient?
- the burden of drugs vs. control of symptoms
- side effects of drugs
- uncertainty of prognosis (eg. should we continue life-prolonging drugs such as antibiotics)
- route of delivery (oral route not really an option)
True or false?
A dry mouth in a dying patient can be treated with mouth care and a drip of parenteral fluids
False
Only mouth care is effective
What is the death rattle and what causes it?
- a noisy, ‘rattly’, wet breathing noise
- normal secretions that a dying patient is too weak to clear
What is Cheynes-stokes breathing?
- Pattern of breathing:
- involving a fast, shallow breathing,
- followed by slow heavier breathing,
- and moments without any breath at all (apnea).
What 3 drugs can treat secretions, and what is used to deliver them?
- Hyoscine butylbromide
- Hyoscine hydrobromide
- Glycopyrrhonium
Infusion with a syringe driver
What are the disadvantages of treating secretions in a dying patient with suction?
- it is very interventional
- can only be done in a hospital (no equipment at home)
Why are non-oral routes used for delivering medication to dying patients?
- They are not alert enough to receive drugs
- They have dry mouths and struggle to swallow
- They are not eating
True or false?
In the last few days of life we manage breathlessness by finding the cause and treating this
False
prior to the last few days of life this would be true
What is the doctrine of the double effect?
- 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
What does “anticipation of problems” refer to when treating a dying patient?
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
What are 3 key essentials of pharmacological symptom control?
- a non-oral route
- anticipation of problems
- stop medication that is not helping symptoms
How do we manage pain in dying patients?
- opioids, dose dependent on need
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?
True
Oxygen is often intolerated in the last days of life (patients often push away the mask or nasal tongs)
What drugs can we use to reduce the feelings of breathlessness if it is not feasible to address the cause?
- opioids
- benzodiazepines
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?
- Midazolam (sedative, anxiolytic, amnesic)
- Haloperidol (antipsychotic)
- Levomepromazine
these drugs can paradoxically worsen agitation
What is one of the most distressing symptoms for a patient?
Dry mouth
What is a syringe driver?
a device that administers medicines subcutaneously over a period of time