Management of the Actively Dying Patient / The Last Days

Question 1

What resources are needed to provide EOL care at home?

Answer 1

• 24 hour access to support
• family physician
• primary palliative home care
• 24 hour pharmacy access
• early planning

Question 2

What factors need to be considered if a dying patient needs to be transferred to hospital?

Answer 2

• PCU
• private room
• palliative care
• nurses
• social workers
• spiritual care
• trained volunteers

Question 3

How do you assess patient’s and family’s understanding/insight into dying process?

Answer 3

• Family meeting
• can observe their interactions
• Important to ask what is known about illness and prognosis

Question 4

What issues should be reviewed at EOL family meeting?

Answer 4

• introductions
• opportunity for agenda setting
• Answer questions about illness and progression
• Ask about concerns or fears about dying
• Review advanced directive
• REview wishes for tissue and organ donation
• Review SDM
• Ask about spiritual history
• special rites or rituals needed
• ASk about funeral
• Ask about past experiences with death and dying
• Discuss coping skills and support
• Discuss normal feelings of grief
• Bereavement risk assessment
• Financial concerns re medications, equipment.
• Compassionate Care Benefits - 8 weeks of employment insurance benefits for people caring for dying family members.

Question 5

List 6 common medical problems in EOL

Answer 5

• Pain
• Dyspnea
• Delirium
• Secretions
• Nausea
• Constipation

Question 6

What changes are expected at EOL?

Answer 6

• progressive weakness
• drowsiness
• unable to eat
• unable to drink.

Question 7

How to counsel re: hydration at EOL?

Answer 7

• Trial considered if reversible cause that hydration might correct
  
  • OIN
• Otherwise, will not prolong life
• increase edema, ascites and secretions
• pulmonary edema
• Impeccable mouth care can alleviate thirst

Question 8

How to counsel re: nutrition at end of life?

Answer 8

• as death approaches, the body does not feel hunger the same way
• does not require food in the same way
• forcing food can lead to :
  
  • nausea
  • aspiration
  • guilt, pressure to please

Question 9

List signs of imminent death

Answer 9

• Cheyne Stokes breathing
• Decreased consciousness
• mottling of hands, legs and feet
• cool extremities
• apnea

Question 10

Management of Symptoms at EOL

Answer 10

• Pain
  
  • check for urinary retention
• Dypsnea
  
  • fan, avoid overcrowding, 02 prn
  • opioids
  • midazolam
  • methotrimeprazine
• Nausea
  
  • sc meds
  • constipation may aggravate
• Constipation
  
  • manage as long as possible
  • to avoid pain, nausea, distress
  • suppositories, enemas
  • stop laxatives if death in short days
• Secretions
  
  • glycopyrrolate
  • scopolamine
  • atropine 1% drops sl q4h prn
  • positioning
  • avoid suctioning
  • lasix if pulm edema
  • bladder catheter
• Delirium

Question 11

Delirium at EOL

Answer 11

• reversible in 30-70% palliative care patients
• early ongoing screening
• altered sleep wake cycle
• dreams
• restlessness
• agitation
• hallucinations
• moments of cognitive clarity
• intermittent, fluctuating
• rapidly escalating pain at EOL with rapid opioid titration –> delirium from OIN

Treatment

• neuroleptics
• opioid rotation if time
• palliative sedation

Question 12

How would you support the family during the quiet time before death?

Answer 12

• “wish you could give her something to end it right now”
• common thought, do not dismiss it
• can bring feelings of guilt
• offer reassurance if patient is comfortable
• may need time to prepare for what is happening
• encourage families to care for each other, eat and drink, take breaks

Question 13

List things that need to happen at the time of death

Answer 13

• cultural and religious values and riutals observed
• death notification
• transfer to funeral home
• coroner involvement
• death certificate within 24 hours
• reflect on relationship with patient
• allow time and space to acknowledge the loss

Question 14

List 7 important things on a checklist for caring for patients at EOL

Answer 14

• Reflect on your own grief
• Conduct a family meeting
• Review medications and interventions and modify for EOL
• Develop and discuss a plan of care and plan for symptoms
• PRovide ongoing support and education to patient, family
• Review goals of care and modify care plan
• Support the family in bereavement

Question 15

PEARLS For EOL

Answer 15

1. Know what a good death can be like
2. There is such a thing as a good death
3. Know the patient, family, resources in their community
4. Keep bedside care as simple as possible. Essential medications only, avoid lab and vital signs if not beneficial.

Question 16

Employment leave for caregivers in Canada

Answer 16

• Compassionate Care Benefit
  
  • federal program
  • 26 weeks EI for people caring for dying family member
• CPP survivor benefit
  
  • death ebenfit (one time payment)
  • Survivor benefit (monthly pension payments)
  • Children’s benefit (monthly benefit,child < 18, or 18-25 in post secondary education)