End of life care

Question 1

A 78 year old woman has terminal cancer and is expected to die within a few days and is documented as NFR. She is semiconscious but seems distressed, tachypnoeic and agitated and is making gurgling noises which are distressing the family. How would you manage this situation?

Answer 1

Introductory
These clinical findings of progressive deterioration are in keeping with the terminal phase of this illness characterised by terminal secretions which leads to the noisy rattling breath.

Mx

• consult in conjunction with MDT pall care team
• clarify the goals of care with the family (keep patient comfortable is most likely)
• counsel on normal process of death/dying, ensure care provided meets sociocultural expectations and is comfortable/dignified for the patient

Question 2

End of life care - History

Answer 2

History
Key points to elicit
- NFR, ACD, details of end of life wishes
- discern key family concerns, gather their understanding of the processes that are occurring
- culturally sensitive approach, therapeutic alliance paramount
- sx: pani, agitation, resp secretions, breathlessness, nausea, vomiting, etc
- Review medications
- ask about reversible causes of increased distress (constipation, UTI, bladder retention, etc)

Question 3

End of life care - Examination

Answer 3

Examination

• aim to determine the source of the pain
• cardiorespiratory examination
• GCS

Question 4

End of life care - Investigations

Answer 4

Investigations

• Nil at this time
• bladder scan if suspected retention to alleviate pain/agitation

Question 5

End of life care - Management

Answer 5

Management
All care is supportive
- consult with pal care and nursing staff

Setting

• single room, clarify ideal settings, ask if anything to make more comfortable
• ensure ward cohesiveness, everyone on same page

Treat any reversible causes of pain/agitation

• bladder retention: decompress
• constipated: aperients/suppositores
• agitation: benzo’s
• secretions: anticholinergics (glycopyrelate)
• pain: morphine

Supportive

• withdraw any unnecessary medications
• ensure adequate hydration and nutrition
• dyspnoea - 02 as required/facial fans
• antiemetics for any N/V
• reassure family about normal process of dying, correct any misperceptions about process of dying
• arrange any appropriate spiritual/additional support
• explain respiratory secretions are normal