End of life care

Question 1

What are the cardinal symptoms/signs of the dying patient?

Answer 1

• Reduced physical activity
• Confusion, drowsiness, agitation
• Decreased intake of food and fluids
• Audible respiratory secretions
• Apnoeas and Cheyne-Stokes breathing
• Slowing of HR, lowering of BP
• Decreased urine output

Question 2

What are the 5 terminal symptoms to treat in a palliative patient?

What are the 3 key things nurses care for in a palliative patient?

Answer 2

• Agitation/ delirium
• Pain
• Dyspnoea (and secretions)
• Nausea/ vomiting
• Fatigue
• Pressure area care
• Incontinence
• Mouth care

Question 3

Which PRN medications should be prescribed for a dying patient and what are their indications (6)?

Answer 3

1, Morphine: pain and SOB

2. Haloperidol: agitation
3. Benzodiazepines: agitation
   Midazolam: short acting injection
   Clonazepam: longer duration buccal, used at home
4. Metaclopramine: NV
5. Microlax enema or suppository (Sodium citrate/sodium lauryl sulfoacetate/glycerol)–> osmotic and lubricant
6. Glycopyrronium bromine (anticholinergic similar to atropine but doesn;t cross BBB): respiratory secretions

Question 4

In a palliative patient which medications should be continued (2 reasons)

Answer 4

• Any medication which prevents symptoms worsening

EG: 
Rate control for AF
Diuretics
Antipsychotics
Anticonvulsants
Pain meds

• Any medication which could cause withdrawal symptoms

EG:
benzos

Question 5

Which 4 medications can you administer via syringe driver?

Answer 5

• Morphine
• Metaclopramide
• Midazolam
• Haloperidol

Question 6

What are the risk factors for ‘complicated grief’- grief overshadowing all else in a persons life, leading to psychiatric syndromes (7)?

What should be the initial management of such people?

Answer 6

• Sudden death
• Traumatic death
• Accumulated loss
• Loss of a child
• Suicide
• Alcohol or substance abuse
• Past depression
• Referral to a social worker and/or grief counsellor

Question 7

What non-pharmacological treatments for symptoms should be given to pall care patients?

Answer 7

Fatigue: patient and family education, encourage pacing

SOB: cool air flow, light, calm room

Agitation: Familiar nurse, family presence, spiritual guidance if requested, privacy

Bowel care: help with mobilisation and continence