Recognising and managing symptoms of death Flashcards
Why is it important to recognise dying?
Prevent unnecessary tests and interventions
Maintain dignity and privacy
Plan for control of symptoms
Enable choice over where death occurs
Prepare and support family members
Enable for spiritual and emotional support to be made available- e.g. priest visit
Allow time for goodbyes
To discuss funeral plans and wills (ideally done earlier with advance care planning)
What are some signs that develop in the last few weeks of a person’s life indicated that they are nearing the end of their life?
Decreased independence Decreased mobility Decreased appetite Increased fatigue and sleep Cognitive slowing and impairment Worsening symptoms
General decline in functioning
What are some signs/symptoms that someone is in their final days or hours of life?
Profound weakness
Bed Bound
Unable to swallow
Reduced consciousness and drowsiness
Circulation changes- cool, pale, mottled skin, oedema, cold hands and feet
Breathing change- cheyne stokes (irregular breathing), rattle (due to build up of secretions in the airway)
What is cheynes stokes breathing?
This is an irregular pattern of breathing that can develop as someone approached death. Shallow breathing is alternated with periods of deeper, rapid breathing.
What causes the rattle as someone approaches death?
A build up of secretions in the airway
What are key priorities in the management of a dying person?
Individualised care
Consideration of persons wishes
Follow ACPs, ADRT, DNAR
Communicate clearly and considerately
Involve patients and family in care decisions
Understand the needs of the family members
Follow individual care plan
Prove spiritual support for patients who want it
What are some symptoms that may be experienced in dying patients which need to be managed?
Pain
Anxiety
Breathlessness/Respiratory secretions
Confusion/Delirium
What is an ideal way to provide analgesia to dying patients?
Background pain can be managed using a continuous subcutaneous infusion of morphine which can be delivered using a syringe driver. The rate of delivery can be adjusted according to the patients pain levels.
Immediate release morphine- e.g. oramorph or fentanyl should be prescribed for breakthrough pain. This is for PRN. Normally the oramorph is 1/6th of the daily dose of morphine.
What should be used for nausea during dying, how should this be delivered?
Antiemetics should be given via continuous subcut infusion. Metoclopramide is a prokinetic agent that helps to counteract the gastric stasis that can occur due to morphine. It is a D2 antagonist.
Levomepromazine acts on many receptors and is used widely to relieve nausea in patients close to death. Dose 6.25mg PRN SC.
What might cause breathlessness in dying patients?
PE
Infection (Patients are likely immunosuppressed)
Effusion due to malignancy /infection
Tiring effort of breathing in cachexic or fatigued patients
Anaemia as marrow production decreases
Fear and anxiety causing breathlessness
Direct effect of tumour- e.g. airway obstruction, SVC obstruction, metastatic spread
How can breathlessness be managed in dying patients?
Consider whether the cause should be investigated, is it right for invasive investigations?
Address and talk about anxiety to try to calm patients- don’t let people get anxious on their own
Conservative- Calming conversations, relaxing atmosphere, aromatherapy, positioning
Oxygen
Opioid- e.g. Morphine 2.5 mgs SC PRN (Reduced respiratory drive)
Benzodiazepines (reduce anxiety that could be driving breathlessness- Midazolam 2.5 mg SC PRN)
Why are morphine and benzodiazepine useful for treating breathlessness in dying patients?
Morphine reduces response to hypercapnia and hypoxia and so reduces the sensation of breathlessness.
Benzodiazepines reduce anxiety that could be driving breathlessness.
How should you manage a death rattle in dying patients?
This is a distressing feature and it should be explained to patients and family members that it is due to a build up of secretions in the airway that occur as the body begins to fail.
Reduce or stop artificial hydration or nebulisers
Consider antisecretory antimuscarinic e.g. buscopan
What antisecretory antimuscarinics may be used to manage the death rattle in dying patients?
Buscopan (Hyoscine Butylbromide)- 20mg SC, Repeat if needed. Consider syringe driver 60-120mg/24 hr
Hyoscine Hydrobromide- 200-400mvg SC, also available as transdermal patch
Glycopyrronium- 200mcg SC, repeat if needed.
What should be done to manage confusion of delirium in dying patients?
Delirium is an acute onset of a decline in cognition with features of agitation, confusion, hallucinations and delusions. It can have a number of causes and these should be managed where appropriate.
