Terminal Care

Question 1

Which symptoms may indicate that end of life care is needed?

Answer 1

Profound weakness
Loss of interest in food & drink
Too weak to swallow meds
Confined to bed for most of the day
Drowsy for extended periods  
Disorientated
Severely limited attention span
Terminal restlessness
Death rattle

Question 2

What is death rattle?

Answer 2

Noise produced by movement of secretions in the upper airway

Reposition or hyoscine butylbromide

Question 3

Why are IV fluids not advised in end of life care?

Answer 3

Increased peripheral & pulmonary oedema

Increased incontinence

Question 4

What are the 4 main types of medication used in end of life care? Through what route are they preferred?

Answer 4

Preferred subcutaneous

Anxiolytics
Analgesic
Antisecretory
Antiemetic

Question 5

Which drugs are unsuitable to be administered via syringe driver?

Answer 5

Diazepam
Chlorpromazine - sedative & antiemetic
Prochlorperazine - sedative

Question 6

What is involved in good mouth care?

Answer 6

Salivary stimulation - e.g. pilocarpine
Cold, unsweetened sips of water, ice lollies
vaseline for lips

Question 7

At what rate are drugs administered on a syringe driver?

Answer 7

mm per hour

Question 8

Where can a syringe driver be inserted?

Answer 8

Chest
Abdomen
Upper arm/thigh
Avoid oedematous areas

Question 9

What functions should be observed and for how long to confirm death?

Answer 9

Observe for 5 mins minimum:
Central pulse
Heart sounds - 2 minutes
Respiratory sounds - 3 minutes 
Response to verbal/painful stimuli 
Absence of pupillary light response - fixed & dilated
Absent corneal reflex
Absence of motor response to supraorbital pressure

Question 10

What occurs to the pupils after death?

Answer 10

Fixed & dilated

No response to light

Question 11

What doctor can sign a death certificate?

Answer 11

Must have seen the patient during their current illness
Must have seen patient within last 14 days
Does not need to see body before signing

Question 12

When must a death be registered in England?

Answer 12

Within 5 days

Question 13

When should you aim to write the MCCD (death certificate)?

Answer 13

Within 24 hours

Question 14

What does section 1a, b,c & d mean in the MCCD?

Answer 14

1a: immediate direct cause of death
1b,c,d: sequence of conditions that lead to 1a
E.g. 1a: aspiration pneumonia
1b: motor neurone disease

Question 15

What does section 2 on the MCCD signify?

Answer 15

Significant other co-morbidites contributing to death

E.g. 2: , NIDDM, AF

Question 16

What is signified as abnormal grief?

Answer 16

Lasting > 6 months
Chronic - intense & prolonged
Inhibited - delayed response 
Exaggerated - anxiety 
Masked

Question 17

What support services are available for grieving relatives?

Answer 17

Macmillan

Cruse

Question 18

What percentage of deaths are referred to the coroner?

Answer 18

12%

Question 19

If a death does not have to be referred to the coroner what form is filled to release the body?

Answer 19

Pink Form B

Question 20

How many reasons are there to refer a death to the coroner?

Answer 20

11 (poster on your wall)

Question 21

What drugs would you not stop in a patient who is terminally ill?

Answer 21

Anti-epileptics
Hypoglycaemics
Corticosteroids - if used to reduce ICP

Question 22

Why is a side effect of levomepromazine?

Answer 22

very sedating

Question 23

What are common symptoms in the last 48 hours?

Answer 23

Death rattle 
Restlessness 
Breathlessness 
Confusion 
N&V