Palliative Care: Death in Numbers, Death in Art, and the last hours

Question 1

1 Fear of Ppl

Answer 1

Public speaking (not death)

Question 2

Where do ppl prefer to be at EOL vs where do most ppl die

Answer 2

HOME is preferred but hospital is most common place of death. About half of those dying in hospital are in ICU

• Hospital stay at EOL associated with worse QOL and bereavement
• Palliative care increases QOL in seriously ill and hospice increases QOL at end of life

Question 3

What do people want at end of life

Answer 3

Most important aspects of dying are:

• having dedicated decision maker
• financial orders in order
• knowing what to expect about prognosis
• knowing what to expect about physical condition
• maintain dignity
• pain well controlled

Question 4

What is Hospice and how is it different than palliative care

Answer 4

Specialized form of PC focused at EOL care

• both philosophy and delivery system of care
• DEPENDENT on prognosis (= 6 mo) (would i be surprised if this pt died in next year)
• not trying to fix what can’t be fixed

Question 5

Discuss physicians role after pt dies

Answer 5

Notice pt unresponsive
Absence of respirations
Absence of heartbeat
Absence of cranial reflexes (pupils fixed, no corneal reflex)

• Document Death note in chart
• After death, care focuses on loved ones
• offer chaplain support
• okay to touch and talk to the body
• let family have the time they need; families may have post-death rituals
• Your role isn’t to make it all better. We grieve. Most important to let family know you are there for them; words don’t matter as much
• Be genuine (say nothing, so sorry for your loss, i’m here for you
• Listen to them (stories/memories)–NOT a time to go over medical details or talk about yourself

Question 6

Describe communicating with a dying person

Answer 6

• Distressing to families– time when they want to communicate the most
• Assume pt can hear everything
• Talk as if they were fully conscious
• Encourage the family to say the things they need to say
• Some pts may be waiting for “permission” to die from loved ones

Communicate with family

• educate on what to expect (changes they may see, feel, hear)
• We can’t control when pt will die but focus on comfort
• Self care
• Support
• Avoid telling family over the phone
• If present during pronouncement, be respectful and allow them to stay in the room

Question 7

Characterize physiologic changes that accompany the dying process

Answer 7

• Active dying process takes hours to days; sudden death uncommon, rarely occurs over weeks
• These changes aren’t what we see in everyday pts but are NORMAL during dying process. We are bad at predicting death
• Bedbound from weakness/fatigue
• Loss of ability to close eyes/mouth
• changes in skin color/temp (may fluctuate in extremes in temp)
• Loss of bowel sounds
• Cardiovascular, Neuro, Resp
• Changes most apparent to family breathing, altered consciousness, decreased appetite/fluid intake
• Anorexia (food can be nauseating, increased aspiration risk, not utilizing nutrients, may be protective). Pt NOT starving even though family worries they are. Help educate family and do other things to show they care (keep mouth moist/clean, etc). No evidence artificial nutrition/hydration improves QOL–can be harmful (edema/dyspnea)

Question 8

Characterize physiologic changes that accompany the dying process

Answer 8

• Active dying process takes hours to days; sudden death uncommon, rarely occurs over weeks
• These changes aren’t what we see in everyday pts but are NORMAL during dying process. We are bad at predicting death
• Bedbound from weakness/fatigue
• Loss of ability to close eyes/mouth
• changes in skin color/temp (may fluctuate in extremes in temp)
• Loss of bowel sounds
• Cardiovascular, Neuro, Resp
• Changes most apparent to family breathing, altered consciousness, decreased appetite/fluid intake
• Anorexia (food can be nauseating, increased aspiration risk, not utilizing nutrients, may be protective

Question 9

Cardiovascular Changes

Answer 9

• hypotension, tachycardia –> bradycardia (within minutes maybe hours of death)
• Peripheral cooling cyanosis
• Decreased urine output
• Mottling of the skin (reticular pattern)
• DO NOT recommend fluids

Question 10

Changes in Breathing during death

Answer 10

LOOKS DIFFERENT

• increased or decreased rate
• rapid or shallow
• deep, slow
• apnea
• Cheyene- Stokes breathing–crescendo/decrescendo with apnea

SOUNDS DIFFERENT

• buildup of saliva/mucous–gurgling/rattling
• Pharyngeal muscles relax– snoring

Management

• educate family, positioning discontinue IV, suctioning doesn’t provide comfort, do not need to add O2
• Secretions: Anticholinergics (atropine drops SL; scopolamine; glycopyrrolate)
• Dyspnea (nasal flaring, accessory muscle use)–Opioids (no evidence they hasten death)

Question 11

Signs that death has occurred

Answer 11

• Not breathing
• No pulse
• grey-ashen skin, cold
• eyes and mouth may remain open
• stiffening of bod after a while
• body fluids may trickle/seep

Question 12

Signs that death has occurred

Answer 12

• Not breathing
• No pulse
• grey-ashen skin, cold
• eyes and mouth may remain open
• stiffening of bod after a while
• body fluids may trickle/seep

Question 13

After Death: Your own care

Answer 13

• Debrief
• check in with your own feelings
• ok to seek help

Question 14

Take Home Points

Answer 14

• Death = Normal
• Physiologic changes that occur during dying process are normal
• Care for the family
• Care for yourself