Symptoms Flashcards
What is the ‘surprise question’?
“Would I be surprised if the person in front of me were to die in the next six months or year?” - The End of Life Care Strategy (2008)
Probing what the impact of the stage and progression of the patient’s disease, co-morbidities, frailty, age, social and other factors are on the patient’s health.
If the answer is ‘yes’ then you need to follow up with ‘is the patient aware of this?’
Later down the line, you then have to ask yourself - ‘would i be surprised if this patient were to die within the next few days or weeks?’
What kinds of features might indicate that dying is imminent?
Increasing frailty:
Greater symptom burden, reduced appetite, less mobile, more weak and ultimately bed bound
Difficulty swallowing:
Often due to mouth breathing then dry mouth; subsequently makes eating and drinking impossible, increasing suffering
Loss of interest and withdrawal:
As energy is so low, and possibly mood too; may alternatively become agitated, restless and confused; time spend asleep increases with patients becoming more difficult to rouse, then unconsciousness that’s not really a sleep
Circulatory changes:
Peripheral circulation decreases and BP lowers; patient may feel cold and skin may go purple/blue; urine production decreases
Changes in breathing:
changes from normal rate/rhythm, may stop for a while, depths can change - Cheyne-Stokes breathing; coughing and (death) rattling - but this is because they are so relaxed that they make no effort to clear mucous in the upper airways
A sudden event leading to death:
e.g. PE, MI, stroke
What other tools are there for identifying deteriorating health?
The Supportive and Palliative Care Indicators Tool (SPICT)
Covers:
- 2x signs of general deterioration e.g. deterioration in functioning, weight loss, unplanned hospital admissions, persistent and troublesome symptoms, living in a nursing home
- System specific changes in cancer, heart/vascular disease, kidney disease, renal disease, dementia and neurological disease
How can you tell when someone is actually dead?
Absence of carotid pulse >1min
Absence of heart sounds >1min
Absence of respiratory movements and breath sounds >1min (above three should be examined for over a period of 5 mins total)
Fixed, dilated, unresponsive pupils
No response to trapezius squeeze
May also be blueish, dry mucous membranes
What are the most common symptoms experienced by the dying patient?
Pain - 40-99% (underlying condition, bed bound, cant absorb painkillers) - people rate pain control as THE most important thing in dying
Breathlessness - 50-80% (fatigue, positional, infection, oedema, hypoxia, anxiety)
Nausea and vomiting - 70% (metabolic, drug toxicity, bowel obstruction, gut oedema, omission of previous antiemetics, anxiety)
Delirium, restlessness and agitation - 80% (uncontrolled fear, pain, anxiety, metabolic abnormality, medication toxicity, thirst, faecal impaction, urinary retention, spiritual distress)
Respiratory secretions - 90% (when semiconscious, as patient does not clear oropharyngeal secretions; not distressing to the patient but may be for family)
What general principles are important when treating symptoms of a dying patient?
- GCS + capacity
- Preventabiltiy - e.g. regular water drinking, alternating pressure mattress, catheter
- Re-assessment i.e. whenever new symptom arises + when intervention is trialled to see if its beneficial
- Right medication - specific solution to a problem e.g. furosemide for pulmonary oedema
- Polypharmacy - can we stop things? What about side effects?
- Route of medication - PO still tolerated or do we need SC?
- Medication at all? e.g. secretions cleared with repositioning
How much SC morphine should you give?
(Oral dose/2) = X*0.3 = Y/24hrs on an SC infusion
SC can take between 20-60 minutes to work
If 2+ doses have been given consider a syringe driver
How should you prescribe morphine PRN?
PRN dose of morphine = 1/6 the total amount taken in 24hrs
Prescribe up to 1hrly
If no benefit after 2-3 doses then review of patient + drug should be conducted
Important to consider the possibility of breakthrough pain and plan for it so things can move smoothly
How should you prescribe in anticipation of breathlessness?
Morphine 2mg SC PRN up to 1hrly - used for the relief of the sensation of dyspnoea
Midazolam 2.5mg SC PRN up to 1hrly - used for the anxiety associated with dyspnoea
What non-pharmacological methods are there for managing breathlessness?
Opening windows, getting fans
Sit them up in bed
Give oxygen ONLY if hypoxic
What are some causes of N+V at EoL?
Gastric stasis due to drugs such as opioids
Squashed stomach syndrome due to tumour or enlarged liver or ascites, or due to outflow obstruction by tumour
Constipation
Chemically induced nausea due to drugs, such as morphine and antibiotics, or metabolic causes such as renal or hepatic failure, hypercalcaemia, hyponatraemia or ketoacidosis
Raised intracranial pressure due to brain metastases
How do you manage N+V?
Drug:
Lots of choices, some are better for certain causes of vomiting MORE INFO
e.g. haloperidol, cyclizine, levomepromazine, metoclopramide
Route:
Oral medication unsuitable for obvious reasons - often syringe drivers of antiemetics (combined with any oral pain relief etc) are good options
NG tubes:
Can be useful, especially if vomits are large volumes
ANTIEMETICS
ANTIEMETICS
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How do you treat noisy breathing?
Siting upright or on side
Mouth care
Gentle suctioning of the secretions in the mouth
Glycopyrronium 200mcg SC up to every 6hrs - may need infusion for 24hrs if working, review in 24hrs
Or Hyoscine butylbromide/hydrobromide - can give as patches
