Palliative care medicine

Question 1

Signs suggestive of death within days

Answer 1

1. Hyperextension of neck
2. Grunting
3. Reduced response to verbal or visual stimuli
4. Non-reactive pupils
5. Upper GI bleed
6. Death rattle
7. Inability to close eyelids
8. Drooping of nasolabial folds
9. Decreased urine output
10. Pulselessness of radial pulse
11. Cheyne stokes breathing

Question 2

Physiological changes in symptoms

Answer 2

1. Weakness, fatigue, mobility, feeding, bathing, bed sores
   Increased falls risk
   Educate family
   Ensure changing position/appropriate bedding
2. Reduced oral intake
   Can be distressing
   Concerns from family about deH
   No evidence to say benefit of parenteral nutrition to improve
3. Neurologic
   Cheynes stokes->ensure family aware
   Reduced LOC
   Delirium
4. Secretions
   May hear rattling
   Educate, position properly, show family how to cleanse mouth
   May use hyoscine/glycopyrrolate->may dry mucosa
5. Inability to close eyelids
   Artificial tears
   Due to loss of retrorbital fat
6. Loss of sphincter control
   Catheter
   Absorbent pads
   Bladder scanning if concerned re urinary retention

Question 3

Possible benefits of reduced oral intake at end stage

Answer 3

1. Relief from choking and drowning sensation
2. Less coughing and chest congestion
3. Decreased urine output with less need for catheterisation and bedwetting
4. Decreased GI distress w/ less vomiting, bloating and diarrhea, less peripheral edema, less pain
5. Diminished appetite, no thirst
6. Comfortable death

Question 4

Symptom management

Answer 4

1. Delirium
Haloperidol
2. Pain and dyspnea
Morphine
Oxygen if hypoxic
3. N/V
Haloperidol
Prochloperazine, metoclopramide, ondansetron
4. Agitation, seizures
Lorazepam
5. Nursing orders
Diet 
Mobilising
Maintaining IV lines
02 if needed
Oral care maintenance
Bathing
Bed sore prevention

Question 5

Confirmation of death

Answer 5

1. Introduce
2. Expected? Main diagnosis, causes, confirm not for resuscitation
3. Circumstance of death- who found, when
4. Confirm ID
5. R/V patient notes, last entries
6. Inspection
   Movement, breathing
   Cool
7. Response
   Squeeze hand
   Say name
8. Palpate
   Supraorbital fossa
   Feel for PPM
   Carotid and femoral pulses for 2 mintues
9. Auscultate lungs and heart for 2 minutes
10. Check pupils
    Fixed and dilated
11. Sign, date etc. paperwork