End of Life with Dr. Lauer

Question 1

How often does resuscitation actually work?

Answer 1

only about 10%

Question 2

True or false: physicians are pretty good at giving a prognosis

Answer 2

False - they overestimate by approximately 200%

family docs are even worse

Question 3

What’s a better way to give a prognosis instead of giving a number?

Answer 3

says hours to days
days to weeks
weeks to months
months to years etc

Question 4

Describe the trajectories of dying for the following: sudden death, cancer, organ failure (like CHF), dementia

Answer 4

sudden: the duh one - you’re fine until you suddenly die
cancer: gradual slope downward
organ failure: they dip down and then bounce back, but not back to what they once were, so overall the decline is gradual
dementia: they’ll stay at a baseline until they hit a destabilizing event during which they’ll dip down to a new baseline and they won’t go back up afterwards

Question 5

What are anorexia and cachexia?

Answer 5

anorexia - loss of appetite

cachexia - weight loss, specifically with muscle wasting

Question 6

Why do anorexia and cachexia often go together?

Answer 6

the loss of ability to use nutritional substrate is accompanied by a loss of appetite.
the body goes from a anabolic state to a catabolic state

Question 7

Should you tube feed a patient with cachexia?

Answer 7

you CAN, but that doesn’t mean you should - it’s a natural process

Question 8

Why shouldn’t you fail to follow hunger and thirst signals? (especially lack thereof)

Answer 8

you get increased symptoms - abdominal pain, N/V, diarrhea from feeding food to a belly that can’t handle it
edema and urinary retention from fluids that the body can’t handle

Question 9

What do we call the tipping point between living and actively dying? WHen does it USUALLY happen

Answer 9

transitioning

on average happens 1-2 weeks before death

Question 10

What are some features of transitioning?

Answer 10

change in alterness
picking, removing clothes, other stereotyped movements
EOL visions
other excalating symptoms

Question 11

When someone is actively dying, what organs are saved at the expense of others by the body?

Answer 11

heart and brain - the others will start to lose circulation

Question 12

What will lose circulation first during active dying?

Answer 12

lower extemities - color changes, cold, thready or absent pulses

Question 13

What loses circulation after the lower extremities? symptoms?

Answer 13

GU system - incontinence, urinary retention, decreased urine output and renal failure

Question 14

What loess circulation after the GU system?

Answer 14

GI tract - lower first with bowel incontinence, constipation, poor appetite (form poor motility) and hiccups
Then upper - poor oral transit, weak swallow and eventually the inability to manage secretions

Question 15

What loses circulation after the GI tract

Answer 15

upper extremities - often seen at the same time as signs on the face

Question 16

When do you usually see the loss of circulation in the upper extremities?

Answer 16

usually not seen until within hours of death

Question 17

Breathing changes during active dying are diven by changes in what?

Answer 17

metabolism
brain function
end lung function

Question 18

During the early stages of active dying, what happens to breathing?

Answer 18

you get rapid shallow respirations due to weakened diaphragm, using accessory muscles and maybe early acidosis

Question 19

What other respiratory symptoms often accompny this shallow respiraton?

Answer 19

weak or no cough

hypophonia

Question 20

What happens after the shallow respiration?

Answer 20

kussmaul breathing - big deep breathes = hyperpnea

Question 21

What’s the cause of kussmaul breathing?

Answer 21

late metabolic acidosis

Question 22

What are cheyne-stokes respirations?

Answer 22

they’re a sort of crescendo-decrescendo apnea associated with damage to respiratory centers or metabolic encephalopathies

Question 23

What characterizes ataxic respirations?

Answer 23

when they’re reathing and then take LONG breaks in between breaths

Question 24

What’s usually the cause of ataxic respirations?

Answer 24

damage to the medulla

Question 25

What’s the last breathing pattern before death?

Answer 25

agonal respiration

“fish out of water” gasping breaths with apnea

Question 26

Generally, in what order does the brain lose function?

Answer 26

1. loss of higher functions first
2. loss of speech
3. slowed cognition and response
4. dysregulation of temp and circadian rhythms
5. hearing spared until very late
6. pulse/BP stability last to go

Question 27

When do we typically calltime of death? Is it easy to determine?

Answer 27

when they enter cardiopulmonary arrest

often hard to tell because other systems have been shut down for hours to days before they lose a pulse