End of Life Care

Question 1

Outline the Symptomatic Treatment for someone who is breathless at the end of life?

Answer 1

1) non-drug:
- positioning
- oxygen
- fans + open windows (sensation of air)

2) Pharmacology:
- antibiotics
- diuretics
- steroids
- anticoagulants
- bronchodilators

3) Specific drugs
a) opioids (SA morphine) - turn down
b) benzodiazepines (lorazepam - anxiolytic)

Question 2

What would you do to confirm someone’s death?

Answer 2

Confirming Death
• Address family
○ Ø ask to leave the room - but give them the option
○ Explain what you will do (briefly) - just formality
• Steps of confirming absence of signs of life
1) Response = Ø
2) Heart sounds = listen for apex beat for 1min
3) Carotid pulse = feel for 1 min
4) Breathing = listen to anterior fields for 1min (or visible signs of respiration) – Ø signs of spontaneous respiration
5) Pupillary reflex = bilaterally – fixed + dilated
• Documentation
○ Time of examination
- = legal time of death
- But if ambulance officer / nurse has documented absence of breathing prior to doctor’s examination → can take that as the date + time of death
○ Findings of examinations
○ Sign it off
○ Death certificate
- Cause of death
- Other possible contributing factors
○ Reportable death
- Death due to accidental injury
- Procedural death = death resulting from a procedure
- Death of an unknown person / cause
- Death in custody / care
- Death of involuntary pt

Question 3

What are some social factors to consider when thinking about death in the hospital environment?

Answer 3

• Ask the pt / family
• Religious
○ Last rights - Catholicism / Christianity
○ Muslim - some pts need to be facing Mecca
○ Buddhist - some request the body be left undisturbed for a # of hrs following death
• Funeral
○ Does not need to have the funeral planned
○ Pt often kept in morgue until sorted out
○ May give family name of funeral director

Question 4

What are some early indicators that someone is dying?

Answer 4

○ ↓apetite / thirst
		○ Drowsiness
		○ Δ breathing - slowed, Chain-Stokes, apnoea, audible respiratory secretions ("death rattle" - final days/hours) 
		○ Mobility - most become bed-bound
		○ Fx decline -
		○ Features specific to the condition

Question 5

What are some things you should prepare when you see early signs of decline?

Answer 5

○ Preparation
			- Mental preparation of pt + family
				□ Communication
				□ Addressing concerns
			- Legal preparation
				□ Advanced care plan (common law) - precedence
					Consolidate discussion, written, substitute decision maker. Happens over time (less legally binding) 
				□ MPOA / POA
				□ Will
				□ Refusal of treatment certificate (statute law - office of public advocate). 
			- Practical preparation
				□ Funeral

Question 6

Outline a good way to have a discussion about of End of Life Decision making?

Answer 6

Spectrum of interventions - try to find where your treatment team is and where the patient is and find overlap:

• one end euthanasia
• usual med withdrawal
• antibiotics, transfusions
• investigations
• fluids
• nutrition
• treatments
• symptom control
• complications
• CPAP
• ICU
• ventilation

main ones to discuss

1) sedation (how much?)
2) fluids
3) euthanasia