Objectives. By the end of this session you should be able to: Identify three physical symptoms which would suggest a patient is deteriorating. Discuss possible clinical intervention for symptom management.Identify and discuss the challenges faced by health care professionals when caring for dying patients. .
1. End of Life Care Kara Fereday
2. Objectives By the end of this session you should be able to:
Identify three physical symptoms which would suggest a patient is deteriorating.
Discuss possible clinical intervention for symptom management.
Identify and discuss the challenges faced by health care professionals when caring for dying patients.
3. The period where day to day deterioration is occurring and there is increasing weakness, drowsiness, poor appetite, organ failure and peripheral cyanosis. Kaye (1996)
Terminal care refers to the management of patients during the last few days,weeks, months of life. From a point where it is clear the patient is in a progressive state of decline. NCPC (1995)
4. When do you Know? Day to day deterioration
Unable to tolerate oral medication
Profound weakness & withdrawing
Loss of consciousness
Skin colour changes
Temperature changes at extremities
5. Barriers to diagnosing dying Hope the patient will get better.
No definite diagnosis
Pursuing unrealistic futile treatments
Disagreement about patients condition
Failure to recognise key symptoms
Poor ability to communicate with Patient & family.
Fear of shortening life.
6. Principles of a good death Control of Symptoms
Preparation for death
Opportunity for closure
To be able to retain control
To be afforded dignity & privacy
To have access to information & resources
To have control over who is present
To have a choice over where death occurs
7. John is 78 he is in hospital he has cancer of the Lung and is dying.
John has a 25 mcg Fentanyl patch insitu but still has pain most of the time. He is also becoming increasingly restless.
John is married to Maggie who is 74, Maggie is aware John condition is worse. Simon is their son, Simon suspects his dad is dying and would like him to come home, but is unsure how he and his mom will cope.
What are your priorities for John and his family?
8. Principles for Managing Problem solving approach to symptom control
Avoid unnecessary interventions
Review all drugs and symptoms regularly
Maintain effective communication
Ensure support for family & carers
9. Rule Out Reversible Causes Infection
Side effects of recent treatment
Metabolic Hypercalcemia, Hyponatraemia
10. Frequency of symptoms in last three days of life Drowsiness & confusion 55% Moist chest secretions 45% Restlessness/agitation 43% Pain 26% Dyspnoea 25% Nausea & vomiting 14% Nauck et al (2000)
11. Physical Symptoms
Changes in Breathing
Changes in Pallor
12. Agitation/Delirium Disturbance in consciousness with impaired ability to focus or shift attention.
Changes in cognition including memory impairment, disorientation, language disturbance.
Disturbances which evolve over a short time period and can fluctuate during day.
American Psychiatric Association (1994) Criteria for diagnosis of delirium
13. Restlessness /Agitation Terminal restlessness: an increased purposeless movement in a patient who is near death. (Lovel 1994)
Agitation: mental distress with or without disorientation. (Faull 1998)
14. Causes of delirium Brain Tumours
Medication – opiods, anticholinergics, steroids.
Metabolic – hypercalcaemia, hyponatreamia, Uraemia
15. Reversible causes: positioning, urinary retention, light, temperature, noise, pain.
Interventions: promote a safe environment, touch & music therapy
16. Treat the cause
Medication : Midazolam 10 - 60 mg Haloperidol 5 - 15 mg Levomepromazine 2.5 - 75 mg
Diazepam 2-10 mg
17. Respiratory Symptoms Changes in Breathing patterns: Cheyne Stocking Carer Information
Reverse the reversible
18. Weakness/Fatigue Fatigue = muscular weakness, lethargy, sleepiness, mood disturbances, difficulty in concentrating. (Bruera 1997)
Easy tiring, decreased ability to maintain performance
Generalised weakness, difficulty in initiating a certain activity
Mental fatigue, loss of memory and emotional ability.
19. Myoclonus Brief shock like activity in one or more muscle groups.
metabolic, medication, biochemical Rectal diazepam Midazolam Clonazepam
20. Chest Secretions: Position change Suction Anticholinergics Hyoscine Butylbromide (Buscopan) Hyoscine Hydrobromide Glycopyrronium
21. Anticholinergic side effects Dry as a bone, blind as a bat, red as a beet, hot as a hare, mad as a hatter.
Dry mouth, heart burn, blurred vision, palpitations, arrhythmias, hesitancy & retention of urine.
22. Acute terminal events Haemorrhage
23. You Clinical Supervision