Recognition and management of dying patient

Question 1

What are the common symptoms and appearance of a dying patient?

Answer 1

Note: all of these must have no reversible cause

• Profound weakness
• Gaunt appearance
• Drowsiness
• Disorientation
• Diminished oral intake- can’t swallow or doesn’t want to
• Poor concentration
• Skin colour changes
• Temperature changes at extremities
• Limbs become cold, pale, mottles, clammy- brain takes away blood supply from limbs & skin

As well as these, patient MUST also have:
- A condition that means it is NOT SURPRISING that the patient is dying.
- e.g. end stage heart failure, metastatic cancer, old age

i.e. If the patient has a newly diagnosed cancer, & displays these symptoms, it cannot be immediately assumed they are dying.

Question 2

What are the medical symptoms of a dying patient?

Answer 2

The big 4:
- Pain
- Breathlessness
- Agitation
- Secretions

• Death rattle - “rattly”, wet breathing caused by normal secretions that dying patient is too weak to clear. Can sound like a person is drowning.
• Cheynes-Stokes breathing - progressively deeper & faster breathing that tails off and results in apnea (temporary cessation of breathing) before restarting. Occurs in cycles of 30 secs to 2 mins.

Other common symptoms:
-Vomiting
- Fitting/seizures
- Bleeds
- Urinary incontinence or retention

Question 3

What are the aims of treatment in a dying patient?

Answer 3

Care shifts from active treatment to managing symptoms.

1. Symptom control
2. Relief of distress
3. Care for the family

Question 4

What are the new priorities for care after the Liverpool care pathway disaster?

Answer 4

1. Recognition that patient is dying.
2. Communication between staff & loved ones.
3. Involve - the family & friends need to be involved in care planning & decision making.
4. Listen - the family & friends need to be listened too & their wishes respected. e.g. if they don’t want to approve organ donation, then they shouldn’t be forced to.
5. Individualise the care plan.

Question 5

What medications are used to manage the different symptoms of a dying patient?

Answer 5

Pain- morphine or diamoprhine

Nausea- levomepromazine

Delirium- haloperidol

Distress- diazepam

Dehydration:
- Don’t give IV fluids - may worsen bronchial secretions.
- Instead wet mouth w/ sponge.
- Mouth care

Secretions:
- Re-position patient
- Suction
- Drugs in a syringe driver:
1. Hyoscine Butylbromide
2. Hyocine hydrobromide
3. Glycopyrrhonium

Question 6

What is a syringe driver?

Answer 6

• A device for delivering a steady infusion
• In palliative care it is usually done subcutaneous
• IV wont work as big veins shut down

Advantages
- Don’t have to give repeated injections
- Maintains constant plasma level
- Can control multiple symptoms - combination of drugs can be given
- Increased independence & mobility
- Reloading once a day

Question 7

What other things do you need to considering when prescribing for a dying patient?

Answer 7

Anticipation of problems - have everything pre-prescribed on drug chart so if needed, it can be accessed quickly. Need 1 of each.
- Analgesics
- Anti-emetics (prevent vomitting)
- Anti-secretory e.g. hyosin hydrobromide or hyosin butylbromide.
- Sedative drugs

Review medications & stop those that are not helping symptoms e.g. ones that were used to actively manage the disease.

Non-oral routes - deliver drugs by an infusion in a syringe driver.

Question 8

What are some issues we encounter while trying to treat a dying patient?

Answer 8

1.Burden of drugs vs. control of symptoms
- Drugs can cause sedation
- Respiratory depression
- “Drying” - the patient already has a dry mouth due to mouth breathing.
- Confusion & amnesia
- These are all symptoms of normal dying anyway, so giving these drugs can actually make normal dying worse.

2. Side effects of drugs
3. Uncertainty of prognosis - always a risk that patient was not dying before, but after you have given strong drugs, they are dying.
4. Route of delivery - many dying patients can no longer swallow so often given injections & continuous syringe drivers.

Question 9

Why is communication with family important?

Answer 9

Important to tell family the patient is dying

Discuss the aims of care w/ the family.

Poor communication is one of the most common causes of family distress & formal complaints.

Question 10

Why talk about death and dying?

Answer 10

• Inevitable
• As humans we invest in beliefs around immortality despite knowing we are mortal
• It matters how we die
• It matter how we live in the time we have left
• Talking about death won’t make it happen any sooner

Question 11

What are the psychosocial needs of someone dying?

Answer 11

• Good interaction w/ healthcare professionals
• Good quality of care systems & procedures (accessibility, efficiency)
• Active involvement in treatment & healthcare decisions
• Quality information on requirements & opportunities
• Involvement w/ social support networks
• Support with Emotion, Feeling states, Worries, Anxieties
• Managing challenges to self-identity

Question 12

What are the psychosocial needs of carers?

Answer 12

• Crucial role - undertake vital care work and emotional management
• Carers’ success in managing their own psychosocial needs impacts their ability to support the patient
• Carers often want to be alongside the patient in medical settings, and in receipt of information about treatments and care