End of Life Care

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 Anorexia/Cachexia Drowsiness Disorientation Poor concentration Skin colour changes Temperature changes at extremities Different symptoms

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 Medication Anaemia Constipation

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 Pain Agitation Changes in Breathing Weakness/Dysphagia Myoclonic Jerking Chest Secretions 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 Alcohol withdrawal Organ failure Infection Pain Constipation Urinary retention Hypoxia

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 Supportive measures O2 Therapy Benzodiazepines Nebulisers Opioids

18. Weakness/Fatigue Fatigue = muscular weakness, lethargy, sleepiness, mood disturbances, difficulty in concentrating. (Bruera 1997) Asthenia 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 Haemoptysis Respiratory Distress Stridor Fits

23. You Clinical Supervision De-briefs Share Plan