End of Life Flashcards
What’s the definition of End of Life (EoL)?
End of Life
- last 12 months of life
- patient likely to die within next 12 months
What types of patients fall into the ‘End of Life’ definition?
Patients likely to die within next 12 months
- imminent death is expected (within days, few hours)
- advances, progressive conditions
- general frailty and co-morbidities
- life-threatening acute conditions
- premature neonates whose prospect of survival is very poor
- patients diagnosed with persistent vegetative state from whom withdrawal treatment may lead to death
What aspects constitute to holistic care (4)?
- Physical
- Social
- Psychological
- Spiritual
Legally binding future care planning documents (2)
- Advanced Decision to Refuse Treatment (ADRT)
- Lasting Power of Attorney (LPA) → health and welfare or finances and property (it’s a legally binding spokesperson)
Informal (non-legal) forms of future care planning (3)
- statement of preferences and wishes
- named spokesperson
- preferred priority of care document
How to recognise that a patient is dying? (terminal phase of illness)
- deteriorate day by day or faster, due to their underlying condition
- becomes progressively weak and fatigued without apparent cause
- realises and express that ‘they are dying’ or report seeing a person that has already died
- reduced cognition, drowsy, lethargic, comatose
- delirious (restless, confusion and agitation)
- bed-bound
- little food or fluid intake
- difficulty in taking oral meds
- have apnoea or altered breathing patterns
- peripherally cold or cyanosed
What’s the North West End of Life Care Model?
Aims to support people to live well before dying with peace and dignity in the place of their choice
What drugs to stop what to commence in abdominal colic symptoms?
- Stop prokinetics → stop metoclopramide
- Start anti-spasmodic → hysocine butylbromide
Anti - secretory drugs (4)
- Octerotide → 1st line
- Hyoscine butylbromide
- Glycopyrronium
- Ranitidine (but can’t be used SC)
Drug for tumour related oedema
Dexamethasone
- corticosteroid
- 5 days trial of Dexamethasone 8mg daily PO (or similar dose SC)
Can we combine Cyclizine and Hyoscine Butylbromide in a syringe driver?
NO
Combination of Cyclizine and Hyoscine Butylbromide in CSCI cause crystallisation
What class of laxatives should be used in end of life care?
Stool softeners should be used
*we should not use laxative stimulants
What meds can we use to reduce nausea and vomiting? + cautions for these meds (5)
- Cyclizine →not with hyoscine butylbromide as cause crystallisation in syringe driver)
- Haloperidol → may cause extra-pyramidal effects
- Levomepromazine → may cause sedation
- Metoclopramide → contraindicated in bowel obstruction
- Ondansetron
What drug classes may cause constipation?
- opioids
- diuretics
- anti-cholinergics
- ondansetron
- chemotherapy
Causes of constipation
- drug-induced
- dehydration
- reduced mobility
- hypercalcaemia
- environmental e.g. lack of privacy
- concurrent disease
- altered dietary intake
- neurological
- intestinal obstruction
What classes of oral laxatives should we use in a palliative (non-end of life) patient?
- combination of stool softeners + stimulant laxatives
- osmotic agent can be added either on PRN or regular basis
Examples of stimulant laxatives (3)
- Docusate sodium
- Senna (tablets and syrup)
- Bisacodyl tablets
What’s the name of combination laxative used only in a terminally ill patient (end of life)?
Codanthramer Strong
(capsules and suspension)
- may cause abdo colic
- may cause skin irritation
- avoid in faecal incontinence
Examples of osmotic laxatives +cautions (3)
- Macrogol → contraindicated in bowel obstruction
- Lactulose → may cause abdo colic and flatulence
- Magnesium hydroxide → avoid in cardiac disease and poor renal function
What drug to use for opioid-induced constipation that has failed to respond to standard measures?
Naloxegol
What to do in case of seizure that does not respond to buccal Midazolam or rectal Diazepam and the patient is to stay at home or hospice?
SC infusion of Midazolam 20-30mg over 24 hours
Management of Superior Vena Cava Obstruction
- Dexamethasone 16mg orally or paraenterally (in one or two divided doses IMMEDIATELY
- discuss with oncologist
- possibility of radiological stenting
Symptoms of Hypercalcaemia
- fatigue
- weakness
- constipation
- nausea and vomiting
- polyuria
- polydipsia
- cardiac arrhythmias
- delirium
- drowsiness
- coma
Management of hypercalcaemia
- rehydration with 0.9% sodium chloride (1-3 liters)
- IV bisphosphonates (after administration of saline fluids)
* check corrected Ca++ after 5-7 days of IV bisphosphonates
Management of suspected metastatic spinal cord compression
- Dexamethasone 16mg PO or convert dose to SC
- prescribe gastric protection
- analgesia (opioid) to enable transport for admission/Ix
- nurse flat (if pain of spinal instability)
- urgent admission and MRI
- radiotherapy or spinal surgery (possibly)
- physiotherapy and OT
- titrate steroids
Management of catastrophic haemorrhage in a terminally ill patient
- member of staff needs to stay with patient to support all the time
- dark coloured towels → to hide blood loss
- Midazolam 10mg IM, buccal or SC
- keep patient warm
- analgesics if needed
What to discuss/consider when we PLAN last days of care?
Discuss:
- CPR
- facilitate a preferred place of care/ death
- how to support fluid/food intake
- when to stop/continue vital obs/ investigations
- start/stop of clinically assisted hydration/nutrition
- review long term meds → stop those that are not longer needed or adjust the route
- anticipatory prescribing
What are 5 key priorities in end of life care
- Recognise
- Communicate - to pt, family, team
- Involve - family, team, pt in decision making, planning
- support - family, pt
- plan
What’s target BM in the end of life care diabetic patient?
6-15
What sides should we avoid insertion of syringe pump drivers?
Alle either due to discomfort, risk of infection, poor perfusion, poor drug absorption:
- oedematous areas
- bony prominences
- irradiated sites
- skin folds, near to a joint or waistband area
- broken skin
Locations on the body where we can consider insertion of syringe driver
- scapula region
- the anterior aspect of upper arms
- anterior chest wall
- anterior abdo wall
- anterior tights
What is anti-emetic preferred in end of life patient with renal impairment?
Haloperidol or Levomepromazine
What corticosteroid is preferred to be used in palliative care?
Dexamethasone
This is because:
- high anti-inflammatory properties
- lower incidence of fluid retention and biochemical disturbance
What’s potency of Dexamethasone compared to Prednisolone
1 mg of Dexamethasone = 7.5 mg of Prednisolone
What time of days should we administer corticosteroids?
- before noon → to minimise insomnia
Use of corticosteroids (as adjuncts) in palliative care - indications
- anorexia
- adjuvant analgesic
- anti-emetic
- obstructive syndromes
- spinal cord compression
- raised intracranial pressure
Adverse effects of steroids use (re to palliative care)
- glucose metabolism → steroids can increase BMs
- insomnia → give before noon
- dyspepsia → give after food; PPI
- psychiatric disturbance
- change in appearance → moon face, truncal obesity, negative body image
- MSK problems → proximal myopathy, osteoporosis, avascular bone necrosis
- Increased risk of infections
- skin changes
- other: hypertension, oedema, pancreatitis
How to stop steroid treatment? (if needed to be monitored)
- when to monitor
- how
Monitored if: 3 or more weeks of steroid treatment, daily dose of more than 6mg Dexamethasone, risk of adrenal suppression, risk of severe symptoms returning
How:
- firstly halve the daily dose (to 4mg a day)
- then reduce slowly by 1-2 mg weekly
Patients on systemic steroids for >3 weeks must be given MEDIC ALERT steroid card
What’s meant by ‘ceilings of treatment’?
How far to actively manage and when to stop e.g. when not to take antibiotics, when not to go to the hospital, when not to treat AKI
