End of life Flashcards
prognostication
process of predicting what a patients outcome is likely to be
- admission decisions
- treatment limitations - IPPV, RRT, extracorporeal life support
- tracheostomy
- invasive procedures
- withdrawal of life sustaining treatments
post cardiac arrest
OOH - < 10% survive to hospital discharge
in hospital - 25% survive to hospital discharge
Resus council - 72 hrsunconscious, GCS motor score 3 or less. 2 of
- absent pupillary light reflex
- Adverse CT/MRI (anoxic injury)
- Absent SSEPs
- Status myoclonus
- malignant EEG
- NSE > 60
Neurological outcome after brain injury
cerebral perfomance category
1 - good
2 - moderate disability independent
3 - severe disability (ambulant –> paralysis) conscious but dependent
4. coma or vegetative state (any impaired consciousness without brain death)
5. brain death
Modified rankin scale
0 - no symptoms
1 - symptoms but no disability - all ADLs
2 - mild disability - not all ADLs
3 - mod disability - help, walks without assistance
4 - mod severe disability - assistance to walk and bodily needs)
5 - severe disability - bed bound
6 - dead
frailty
Clinically recognisable state of vulnerability resulting from age related decline in reserve and function across multiple physiological systems such that ability to cope with everyday or acute stressors is compromised
performance status
initially used to assess patients independence in the context of malignancy
0 - fully active
1 - restricted strenuous activity
2 - ambulatory, self caring, unable to carry out work activities
3 - limited self care, confined to chair or bed 50%
4 - completely disabled confined to bed or chair
5 - dead
palliative care
holistic care of patients with advanced progressive incurable illness, to support patients to live well until they die
focus on symptom management and psychological, spiritual, social support
end of life
patients approaching end of life when it is likely they will die in the next 12 months
end stage is fine; period of progressive disease
futility
perceived non-benefit of treatment
- physiological - unable to maintain acceptable physiology
- quanititative - low chance of succeeding
-qualitative - cannot achieve acceptable QoLec
principles of EOL decision making
equalities
human rights
presumption in favour of preserving life
presumption of capacity
overall benefit
decision making for adults without capcaity
- be clear what decisions must be made
- check of legally binding advance decisions
- enquire whether someone holds legal authority to decide
- take responsibility for deciding which treatment will provide overall benefit, consulting’sg those close to patient
role of family
- provide information about patients wishes, preferences, feelings, beliefs and values
- don’t make decisions
- unless they have legal authority to make decisions on behalf of the patient who lacks capacity
disagreement about decisions surrounding EOLC
- seek advice from colleagues
- independent advocate
- case conference or ethics consultaion
- mediation services
- legal advice, independent court ruling
principles of withdrawing care
- not to prolong death, relieve symptoms and maintain dignity
- likely procedures involved e.g. extubation
- uncertainty about dying process, amount of time
- support
- how symptoms will be managed
withdrawing organ support
- individualised assessment
- stop non-comfort medications
- stop monitoring
- assess relevant symptoms
- sequential reduction in support - vasoactive medications, ventilatory support, extubation
special circumstances
- status epilepticus - continuing sedation
- NIV - weaning support and O2 to air
- MCS / ECMO - reduction in pump and gas flow
- ICD - deactivation
consequences of death for the individual
- cessation of resuscitation efforts
- religious ceremonies
- execution of will
- post mortem examination
- registration and certification of death
- organ donation
- disposition of body
somatic criteria for death
general recognition of death by another person (recognition of life extinct criteria)
- decapitation
- massive cranial disruption
- hemicorporectomy
- incineration
- decomposition / putrefaction
- rigor mortis
cardiorespiratory criteria for death
loss of consciousness
continuous apnoea and asystole
- cessation of circulation - absent pulse, absent heart sounds
- cessation of respiratory system - absent respiratory effort, no breath sounds
- cessation of cerebral function (5 mins after above) - fixed dilated pupils, no corneal reflex, no motor response to pain
time of death
at time of verification of life extinct
1st set of tests in brainstem death
37/ 40 - 2 months VLE
no heart sounds
no respiratory effort or breath sounds
no spontaneous movement or response to stimulation
medical examiner
provides scrutiny of all deaths
provide support for bereaved
improve quality of death certification and mortality data
coroner
independent judicial officer responsible for investigating a patients cause of death in certain circumstances
- who
- how, when, where death occurred
- may involve post mortem or inquest
clinical team responsible for referring appropriate cases
indictions for referral to coroner
- mechanism - unnatural trauma, self harm, neglect, poisoning, notifiable accidents/diseases, anaesthesia, post-operative
- unknown cause of death
- unknown patient
- patient in custody or state detention
coroner conclusions
- natural causes
- misadventure
- suicide
- unlawful killing
- lawful killing (self defence)
- industrial disease
- narrative - described circumstances but not bound by above
last offices
historical term used to describe care after death
- spiritual / cultural wishes
- preparing body for transfer to mortuary
- privacy, dignity
- honouring wishes for organ and tissue donation
if coronial involvement - leave all lines, keep infusions attached but clamped, do not wash or begin mouth care
no coronial - mouth care, tidy, clean, dress
Diagnosing death by neurological criteria
- Evidence of irreversible brain injury of known aetiology
- exclusion of reversible causes of coma and apnoea
- examination of absent brainstem function
DND
preconditions
- brain injury known aetiology
- GCS 3 requiring mechanical ventilation
causes
- intracranial - haemorrhage, TBI, ischaemic stroke
- extra cranial - profound hypoxia
exclusion of reversible causes of apnea and coma
- CVS instability
- PaO2 > 10, PaCO2 < 6, MAP > 60, pH 7.35-45
- drugs
- sedatives, NMB
- reversal agents if needed
- Metabolic
- temp > 34
- Na 115 - 160
- K > 2
- glucose 3-20
- Po4 / Mg 0.5 - 3
- Endocrine - if doubt levels to be taken
red flags DND
- within 6 hours of loss of last reflex
- within 24 hours if cause is anoxic damage
- within 24 hours if rewarming
- neuromuscular disorders
- prolonged fentanyl infusions
- decompressive craniectomy
- steroids in SOL
- posterior fossa or brainstem pathology
- therapeutic decompressive craniectomy
Brain stem testing
Afferent / efferent
- pupillary light response - II, III
- corneal reflex - V / VII
- supra-orbitals pressure - V / VII
- vestibulochlear - VIII, III, VI
- Gag - IX, X
- Cough - IX, X
Apnoea test
baseline ABG
Adjust ventilation to ensure - pH < 7.4 pCO2 > 6
repeat ABG
PreO2
disconnect from ventilator and maintain oxygenation with waters circuit
observe for 5 mins for any ventilation
if none, repeat abg
PCO2 > 0.5 rise
DND challenging
extensive facial injury - unable to perform cranial nerve examination
high cervical spine injury - aetiology of apnoea
ancillary testing - CT angiography
critical care management of brain stem dead organ donor
important as average donates 3.3 organs
standardised mx improves organ retrieval
challenges
- cvs instability
- DI
- Neurogenic pulmonary oedmea
- electrolyte disturbance
- DIC
- hypothermia
immediate objectives in care of heart beating organ donor
- methylprednislone
- identify and treat DI
- switch NA to vasopressin
- correct hypovolaemia
- glycemic control
- stop unnecessary medications
physiological targets - pO2 > 10
- pH > 7.25
- MAP 60-80
- UO 0.5-2
- Na < 150
- glucose 4-10
- normothermia
specific optimisation
respiratory
- LPV
- recruitment maneouvres
- tracheal suctioning / physio
- consider bronchoscopy and lavage
cvs
- correct hypovaolaeia
- CO monitoring
VP 0.5-4units/hr
fluids.metabolic
- 15mg/kg methylprednisolone
- NH water if hypernatraemia
- UO > 4ml/kg/hr give DDAVP
- LMWH
DCD Maastricht criteria
controlled donor = retrieval after expected death (III, IV)
uncontrolled = after unexpected and irreversible cardiac arrest (I, II, V)
I - dead on arrival
II - unsuccessful resuscitation
III - anticipated cardiac arrest
IV - cardiac arrest in brain dead donor
V - unexpected arrest in ICU patient
DCD limitations
eligbilility
containdications
- age > 85
- CJD
- viral haemorrhage fever
- TB
- active cancer generally
- HIV generlaly
susceptibility of organs to warm ischaemia
stages of DCD
- decision to withdraw active treatment
- screening of suitability for DCD
- conset for DCD
- withdrawal ( theatre)
- palliative care
- diagnosis of death circulatory criteria
- retrieval
- last offices
ischaemic time
- ischaemic organ injury and influence outcome of graft
functional warm ischaemic time - starts when sBP < 50 or SaO2 < 70%
- ends when cold perfusion takes place
graft cold ischaemia - starts at cold perfusion
- ends at removal from cold storage
graft warm ischaemic time - starts at removal from cold storage
- ends at reperfusion
Suggested max functional warm ischaemic time
- liver 30 mins
- pancreas 30 mins
- lung 60 mins
- kidney 120 mins
ex vivo perfusion
machine perfusion to improve viability of organs
dcd heart / kidneys
in vivo technique - thoracic and abdominal organs perfused in situ after cerebral circulation isolated
dcd lungs - tracheal intubation after confirmation of death. single recruitment manoeuvre > 10 mins after systole followed by CPAP 5cmh20
