NESB end of life care

Question 1

An 81 year old Chinese NESB male has metastatic lung cancer and is receiving palliative care in hospital. He has end stage renal failure and is not for dialysis. His family are concerned that he is increasingly drowsy and is gurgling when he breathes. The nurse calls you because he is not reusable. How would you assess and manage this situation?

Answer 1

Impression
Two main elements to this situation which need addressing and managing
1 - Family expectations, understanding of situation in setting of NESB
2 - Patient’s clinical deterioration, assessing for reversible causes/ensuring patient comfort and dignity

Goals

• engage with family, involve interpreter as required
• liaise with pal care team as to holistic management plan
• supportive management for patient, family education and reassurance

Question 2

NESB end of life - History

Answer 2

History

• arrange for formal interpreter/utilise phone interpreter
• check notes for management plan, assess for NFR/ACDs in place, discuss plan with Pal care team

End of life symptoms

• Pain
• N/V
• Respiratory distress, excess secretions
• agitation

Other

• family expectations, understanding of the situation
• psycho-socio-cultural issues and understandings

Question 3

NESB - Examination

Answer 3

Examination

Limited in pal care setting, mainly to identify if focal regions of tenderness/pain

Question 4

NESB - Investigations

Answer 4

Investigations
Limited in pal care setting, esp if in terminal phase of illness.
- bladder scan for urinary retention
- comfort obs only

Question 5

NESB - Management

Answer 5

Management
- liaise with Pal care team, manage in conjunction.

Setting:

• private room, clarify ideal setting with family and respect wishes
• Ward cohesiveness - ensure all staff on ward aware of plan and goals of care.

Patient

• interpretor for history, asking if pain, etc
• agitation: benzodiazepines (Midazolam)
• Pain: Morphine
• Secretions: suction, physio, posturing anticholinergics (benztropine)
• N/V: metoclopromide (avoid ondansetron)
• constipation: aperients

Family

• interpretor for communication
• asess wishes/understanding of situation, address misconceptions respectfully and any concerns
• education; gurgling is not painful or distressing for patient, is normal part of terminal phase of illness, is mostly just distressing for the family
• communicate management plan in conjunction with pal care
• spiritual supports as necessary
• grief and bereavement counsellors