Last Days Flashcards
1
Q
Review of declining patient
A
- Diagnosis
- Physical exam/history
- PPS
Symptoms:
- PO intake, appetite
- Functional status
- BMs
- Pain
- Dyspnea
- Nausea
- Fatigue
- Cognitive status
- Review investigations to ensure any possible reversible causes of decline have been considered
- Current meds
2
Q
Resources required for a home death
A
- 24/7 support
- Appropriately equipped care team (family, +/- professional supports) for personal care, symptom assessment, treatment
- Pharmacy for medications with well-planned refills ahead of when death is expected
3
Q
Considerations for transfer to hospital
A
- PCUs may not be available in smaller hospitals
- Consider availability of private rooms in local hospital
- Availability of physicians, nurses, other professionals with palliative care
4
Q
Key items for discussion as EOL approaches
A
- Info and communication (particularly while patient still able to communicate)
- Questions about illnesses and change in status from patient and family
- Review advance directive, preferred location of death
- Organ and tissue donation
- Substitute decision making - Assessment of Family Needs and Resources
- Concerns or fears about dying
- Resources for death at home - Care Education
- Ways to provide comfort care, common symptoms - Emergency Provision
- Who to call, for what, and when
- Link to a 24 hour phone support service - Review of family coping
- Grief and spiritual care needs
- Funeral arrangements
- Discuss anticipatory grief with family, ask about support and coping systems (consider screen for complicated bereavement)
- Financial concerns (meds, equipment, need for respite, employment leave) - Preparing for the family for the dying process
5
Q
Employment leave for caregivers in Canada
A
Compassionate Care Benefit
- Federal programme in Canada, 26 weeks of EI and job security for people caring for dying loved one
Caregiver Benefit (NS) - $400/week if providing >20 hrs care per month
CPP Survivor Benefit
- Death benefit (one time payment)
- Survivor Benefit (monthly pension payments)
- Children’s Benefit (monthly benefit, Child <18, or 18-25 and in higher education)
6
Q
What common medical problems should be discussed at EOL
A
- Pain
- Dyspnea
- Nausea
- Constipation
- Respiratory secretions
- Delirium
7
Q
Changes to expect in someone actively dying
A
- Decreased functional status, more time in bed
- Decreased PO intake (eventually impossible) and warning that pressuring or forcing to eat may cause increased nausea or aspiration
- Survival with no PO intake may be 7-10 days (rarely longer)
- Mouth care, eye care, skin care
- Turning off ICD (pacemakers okay)
- Need to change to subcut meds when no longer able to swallow
- Catheter PRN in case of urinary retention
8
Q
Signs that death is imminent
A
- Cheyne-Stokes breathing (progressively deeper breaths, then lighter breaths until a period of apnea, repeatedly)
- Decreased LOC
- Mottling of extremities
- Cool extremities
9
Q
Excessive respiratory secretions at end of life
A
- ‘death rattle’ can occur in up to 90% of patients
- Advise that it is not uncomfortable, but may be distressing for family
Pathophys
- Increased production of airway secretions
- Decreased mucociliary clearance
- Ineffective cough reflex
- Pulm edema or resp infection
Treatment
- Positioning
- Avoid suctioning (distressing)
- Scopolamine 0.2-0.4mg subcut q2H (crosses blood brain barrier)
- Glycopyrrolate 0.2-0.4mg subcut q2H PRN (does not cross BBB)
- Atropine drops (2 drops SL q4H PRN)
- Lasix if pulm edema is suspected (and consider catheter)
10
Q
Terminal phase - definition
A
Period of irreversible decline in functional status prior to death
Lasts hours to days, occasionally to weeks
11
Q
Signs of the terminal phase
A
- Weight loss
- Profound weakness and fatigue
- Social withdrawal
- Disinterest in food and drink
- Dysphagia and difficulty in swallowing medication
- Refractory delirium
- Changes in breathing
- Drowsy for extended periods of time
- Reduced urine output
- Skin that is cool to touch
- Waxy look to skin
