End of Life Care Flashcards
What are the clinical features of someone reaching the end of their life?
- Spending majority of time in bed or chair
- Increasing dependence
- Multiple co-morbidities
- Unstable or deteriorating symptoms burden
- Weight loss >10%
- Chain stokes breathing
- Cool peripheries and mottled skin
- Reduced urine output
- Incontinent
- Withdrawn and loss of communications
How should someone at the end of their life be managed generally?
- Continue to treat easily reversible problems such as urinary retention
- Stop observations and blood test
- Rationalise medication
- Prescribe PRN EoL drugs
- Consider starting a syringe driver if PO is unsuitable or uncomfortable
- Support wishes to eat and drink as long as patient still wishes
- Give good mouth care
What drugs are given as anticipatory end of life medication?
Pain – Morphine either 1/6th of regular dose or 2.5mg SC/5mg PO maximum every hour
Agitation and anxiety – Midazolam 2.5mg SC maximum every hour or Levomepromazine –6.25mg SC TDS
N & V – Levomepromazine – also sedative 6.25mg SC TDS
Secretions – Glycopyrronium 200mcg SC
Breathlessness – Midazolam 2.5-5mg SC or Morphine 2.5-5mg SC maximum every hour
When prescribing multiple drugs for a syringe driver what is it important to check?
Syringe Drivers – continuous infusion of SC drugs avoiding repeated administration. Make sure not to mix drugs that interact with each other in the same driver.
How should excessive secretions both mucous and serous based be managed at the end of life?
If mucous based i.e. COPD, then need Saline nebs and mucolytic such as Carbocysteine
If excess watery secretions, then Hyoscine Hydrobromide (sedative) or Glycopyrronium. Moving patient to aid draining of secretions is also useful, intermittent suctioning can be done but only if patient is unconscious.
What can be given to managed bowel obstruction and colicky pain at the EoL?
If bowel obstruction and getting colicky pain, then Hyoscine Butylbromide is given to reduce gastric secretions and so reduce obstructive colicky pain.
How should a CPR/Respect form be put in place?
Make sure a DNA CPR form or Respect form is in place
This is a doctor’s decision as CPR is an intervention and doesn’t have to be offered but should still be discussed with the patient and family. Always explain what CPR is and what it aims to achieve and so why is no longer indicated in EoL patients.
How are intractable hiccups managed?
Intractable Hiccups – Chlorpromazine, Haloperidol, Gabapentin or dexamethasone if hepatic lesions.
Describe the WHO performance status?
0 – Fully active without any restrictions. Able to do everything they could before diagnosis
1 – Unable to do strenuous activities but able to carry out light house work
2 – Able to walk and self-care but unable to work. Out of bed more than 50% of the time.
3 – Confined to bed or chair more than 50% of the waking hours, capable of limited self-care
4 – Completely disabled totally confined to bed or chair and unable to do any self-care
5 – Death
