Optimising Care in the Last Days of Life Flashcards
What is a good death?
- A patient with well-controlled symptoms, looked after where they want to be, by carers who are coping.
- Comfortable patient: physically, emotionally, spiritually etc
- Peaceful, dignified
Keys to doing this
- Multidisciplinary team work and communication
- Good communication with family and with healthcare professionals
- Seek advice or refer early to specialist palliative services
- Anticipate probable needs so that immediate response can be made
How to recognise dying?
- Cause of deterioration no longer responding to treatment
Can this be reversed?
- Reversible causes of deterioration no longer appropriate to treat
Should we attempt to reverse?
- Not easy
What are the expected physiological changes in palliative care?
- Changes in obs
- Weakness and fatigue
- Decreased oral intake and swallow reflex
- Decreased blood perfusion
- Renal failure
- Incontinence/retention of urine
- Change in mental state
- Confusion, disorientation, delirium
What is the syndrome of imminent death?
- Time course: 24 hours to 2 weeks
- Variability
- Disease process
- Physical reserves
- Variability
- Family education and anticipatory guidance
- Confirmation of observations
- Repetition
“These are symptoms associated with the normal process of dying”
What are the routes for drug treatment in palliative care?
- Subcutaneous (most common)
- Buccal, rectal, topical
- NOT INTRAMUSCULAR - PAINFUL
What are the phases of syndrome of imminent death?
- “Transitioning” or the Early Phase
- Bedbound
- Incontinent
- Decrease in ability and/or interest to eat or drink
- Cognitive changes
- Social withdrawal, decreased interest in world
- Disorientation
2) Middle Phase
- Tracheal congestion
- Further cognitive changes
- Slow to arouse
- Brief wakefulness/responsiveness
- No oral intake
- Assist family to find alternate ways to “care”
3) Late Phase
- Comatose
- Temperature instability
- Altered respiratory pattern
- Mottling and cool extremities
- Absence of peripheral pulses
Explain communication with unconscious patients in palliative care
- Can be distressing to family
- Awareness > ability to respond
- Assume patient hears everything
- Create familiar environment
- Include in conversations
- Assure of presence, safety
- Touch
What is the general approach to care in palliative care?
- Transition to comfort care if not already in progress
- Stop interventions and monitoring not contributing to comfort
- Treat symptoms and educate as issues arise
- Provide excellent oral and skin care
- Be present and honest, sit down, assist with family concerns/conflicts
- Attend to own emotional responses and support
What factors can be introduced when dying in institutions?
- Home-like environment
- Permit privacy, intimacy
- Personal items, photos
- Remove monitors and unnecessary equipment
- Continuity of care plans
- Avoid abrupt changes of settings
- Consider a specialised unit
What kind of spiritual care can be given in palliative care?
- Deeply personal
- Life’s meaning and purpose
- Religion/God
- Memory boxes, keepsakes, legacies etc.
What symptoms are treated in palliative care?
- Respiratory tract secretions
- Restlessness/agitation
- Breathlessness
- Nausea and/or vomiting
- Pain
Explain who respiratory tract secretions in palliative care are a problem for and non-pharmacological methods of dealing with it
Who is it a problem for?
- Patient
- Family
- Staff
- Other patients
Non-pharmacological methods:
- Educate the family
- Don’t over hydrate
- Reduce or stop parenteral hydration
- Positioning
- Suctioning - rarely, carefully, gently
- Above all do no harm
- Cover or mask
- Music
What are the causes of restlessness/agitation? & how treated?
Consider all reversible causes
- Pain, positioning, breathlessness, nausea
- Urinary retention/bladder spasm
- Impacted rectum/severe constipation
- Severe anxiety, fear, unexpressed concerns
- Drug/alcohol/tobacco withdrawal
- Medication adverse effects
Treatment
- Consider sedation (start low and titrate)
- Choice of drug midazolam vs haloperidol
How to treat nausea and/or vomiting in palliative care?
- If anti-emetic is working and is available as an injectable formulation continue this by syringe driver:
- Metoclopramide
- Haloperidol
- Cyclizine
- Levomepromazine
- Substitute if not available for sub-cutaneous use:
- Metoclopramide in place of Domperidone
- Cyclizine in place of Prochlorperazine
How to treat pain in palliative care?
- Opioids and benzodiazepines are appropriate if used and titrated carefully
- For parenteral use (subcutaneous) in naïve patients
- Morphine sulphate 2.5mg prn; 10mg/24h
- Midazolam 2.5mg prn; 10mg/24h
