T erminal Care End of Life Care E Holbeach Life is pleasant Death is peaceful It is the transition that is troublesome Isaac Asimov Death Denying Culture In Scotland where I was born death was seen as imminent ID: 1036950
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1. Palliative Carefocus on…Terminal Care/ End of Life CareE Holbeach
2. Life is pleasant. Death is peaceful. It is the transition that is troublesome.Isaac Asimov
3. Death Denying Culture“In Scotland where I was born, death was seen as imminent. In Canada where I trained, death was seen as inevitable. In California where I live now, death is thought to be optional.”Ian Morrison
4. Your Experience to date?Dying?How was it diagnosed?How was it communicated?What symptoms did the patient have?How were the symptoms managed?
5. todaySigns your patient may be dying.Common symptoms at end of life.Common pharmacological management of symptoms at end of life.Certifying death compassionately.Care of self.We are keeping it really simple here- just the basics about DRUGS, not some of the more complex things you will see with more experience- (eg- severe terminal restlessness, seizures at EOL, very difficult psychosocial situations etc)
6. What are signs of dying?Why is diagnosing dying important?Why is diagnosing dying difficult?
7. Increasing fatigue- spending more time in bed, lacking energyDecreasing oral intake – food/fluids/medsDecreasing mobility Reduced ability to communicateDecreasing level of consciousnessOther signs...Signs of dying?
8. Barriers to diagnosing dying?Culture of cureDon’t realise/ don’t acknowledge patient is dying until very lateFear/ Difficulty in having the ‘dying’ conversationCultural and spiritual barriersCost of not diagnosing? Any?To the health care systemTo the patientTo the familyDiagnosing dying
9. Even when death seems imminent, we often feel conflicted between discussing it and the desire to provide hope by focussing on treatment options to prolong life.We are often overly optimistic about the potential for treatment to succeedWe then pursue it for far too long, at significant cost and with little benefit to the patient.Grattan Institute. 2014 Dying Well
10. End of Life careWhy is this important?Enhances dignityProvides opportunitiesFor patientFor family/loved onesImproves bereavement outcome
11. What should we do?CommunicateWith patient (if appropriate)With family/carersAllow questionsApproach with sensitivity and honesty – avoid “truth dumping” or “terminal candour”Rationalise Invasive investigationsMedicationsComfort measuresPsychological/spiritual support
12. TERMINAL CARE SYMPTOMSWhat are the 6 symptoms to be ready for?PainNausea + VomitingShortness of BreathAgitationNoisy BreathingDry Mouth7- Psychosocialspiritual distress
13. Symptom 1: Pain- terminologyPain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Breakthrough pain: a transient increase in pain, occurring against a baseline level of otherwise acceptable pain control. Incident pain: a category of breakthrough pain related to a particular event, most commonly movement. Allodynia: pain due to a stimulus that does not normally cause pain. Hyperalgesia: an increased response to a stimulus that is normally painful.
14. Pain in terminal careCan someone unconscious feel pain?Why would someone in terminal stages of life get pain?How do you know if your unconscious patient is in pain?Facial expressions.Movement- restless, agitation.Respiratory rate, heart rate.How do you communicate this to family?
15. Position, Position, Position! Pressure mattress/ turnsdoes turning provide comfort or cause distress?Pharmacology (terminal care here- patient is unconscious!)OpioidsChoices?Mode of delivery?Doses?Non opioids???Pain in Terminal Care
16. MorphineOxycodoneFentanylHydromorphoneNorspan (Buprenorphine)CodeineOther- tramadol, methadonePain in terminal care
17. Opioid naïve patient:Kidneys okay (eGFR>30)Morphine 2.5-5mg SC PRN ½ hrlyKidneys not okayFentanyl 25-50mcg SC PRNHydromorphone 0.5-1mg SC PRN1/2 hrly Already on opioid:Convert background opioid to one of above dependent on renal function to work out 24hour requirment- will often need this in Syringe driver format, but not always.Calculate breakthrough PRN dose….?howPain in terminal care- Rules of thumb!
18. “But doctor… morphine kills!!! Don’t give my mum morphine, I refuse!”
19. Where to find out more?!
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22. Opioid PROBLEMSSide Effects:ConstipationConfusion/ HallucinationsSomnolenceN+VOccasional: myoclonic jerks; itch; sweatingRare: dependence (<1%!!!!)Therefore:USE LAXATIVES regularly whenever opioid prescribed.USE ANTIEMETICS PRNMONITOR and NOTIFY if other Side Effects (consider switching…)
23. Symptom 2: N+VWhy would someone in terminal care get N+V?Drugs (opioids! Recent chemo)Medical condition: SBO, constipation, ↑ICPPsychosocial- fear, anxiety
24. AntiemeticsCommonly used in end of life careMetoclopramide 10mg sc q4h PRNHaloperidol 0.5-1mg SC q4h PRNSpecial cases:Bowel obstruction?NOT maxalon! Use haloperidolParkinsons disease?NOT maxalon, NOT parkinsonsCall pall care!Cyclizine/ prochlorperazine
25. Symptom 3: DyspnoeaWhy would someone in terminal care get dyspnoea?Pulmonary pathologyInfectionPulmonary OedemaCancerOther- Pumonary Fibrosis/ hypertension/ PE etcAnaemiaAnxiety/ distress
26. Terminal Care- Dyspnoea/ SOBTreatmentOPIOID!!!Unclear mechanism of actionLikely direct action on central respiratory centreNO effect of respiratory depression/ oxygenation levels at appropriate doses (small doses)Not clear which opioid is bestStick with what you’re prescribing for pain, and add SOB as indication!BENZODIAZEPINESRemoves anxiety associated with dyspnoeaShouldn’t use BDZ without opioidNasal Prong oxygen -but risk of drying out oral/nasal mucosaPositioningFluid managementFan/ open window
27. Symptom 4: AgitationWhy would someone in terminal care get agitation?Multifactorial at end of life:Physical causes:PainConstipationUrinary retentionInfectionMedication changes/ withdrawal+many others!Psychological CausesTerminal Restlessness
28. Agitation- managementManage underlying cause if presentCheck for retention, assess for pain, check bowel chartTrial non-pharmacological approaches TOGETHER with pharmacological:Eg- re-position, music, family/ staff presence, reassuranceBenzodiazepines:Midazolam 2.5mg SC q1hClonazepam drops S/L 3-5 drops 3/24 PRNAntipsychotic medications:Haloperidol 0.5-1mg S/C q4h
29. Symptom 5: Noisy BreathingLower Respiratory Tract (pneumonia) origin vs Upper Respiratory (saliva/ vocal chords)Management:FAMILY EDUCATION:Not felt to be distressing to patient- more distressing to people sitting beside!Positioning- head down, side to sideSTOP fluidsGlycopyrollate 0.2-0.4 mcg S/C QID max 1.2mg/dIf someone has pneumonia, this may not work, hence edcuation of family is key.
30. Symptom 6: Dry MouthWhy do people get dry mouth?Management:Regular oral hygieneShow family/ loved ones how to do itHow do you do it?What can you use?Medications:Artificial saliva sprayLubricant lip balm
31. So….“please write up ‘palliative meds’ for Mrs X”What are you writing up?Checklist!PainAlready on opioid?- convert it!Renal function?N+VSOBAgitationNoisy breathingDry Mouth
32. What about my ‘6th’ symptom:Psychosocialspiritual distressREALLY important. Too big to be covered here.Pall Care CNCs do this AMAZINGLY well!Distress refers to patient, but also to family/ loved ones
33. Cases:Mrs Mabel Mann 98 yo form HLC nursing home admitted with drowsiness. Na+ 167. diagnosed as dying by med reg. currently looks comfortable. Gone to ward, admitting team forgot to write drug chart…Would you prescribe any PRNs?If so, what?
34. PainAlready on opioid?Renal function?N+VSOBAgitationNoisy breathingDry MouthFentanyl 25-50mcg SC PRNIndication Pain and SOBMaxalon 10mg SC QID PRNIndication N+VMidazolam 2.5-5mg SC PRNIndication AgitationGlycopyrollate 0.2-0.4mg q4h PRNIndication noisy breathing“regular oral hygiene”
35. Great! You’re nailing EOLC! Totally have this covered. Nurses are loving you!You go to put the drug chart back on the bed where you found it, and daughter asks what you have done…..
36. Great! Still nailing it!10 hours later nurses page you to review:Increased work of breathingHas had x3 breakthrough fentanyl for SOBWhat is going on?What do you do?
37. Syringe driversWhen to use themWhen someone needs constant background medicationsIf someone has previously been on decent doses of long acting opioids (eg>10mg BD targin) that they can no longer take orallyIf someone has constant symptoms (any of the 5: pain, N+V, SOB, agitation, noisy breathing)
38. What are you going to put in the syringe driver? What do you want to know? Who will you call?Drugs used in last 10 hours?Has had 150mcg fentanyl Has had 2.5mg midazolamHow comfortable is she looking now? Did the above drugs work?So:Syringe driver:Fentanyl 200-300mcg/ 24hoursMidazolam 0-10mg (!)/ 24hours How do you explain to daughter?
39. Next day:Has had further 250mcg fentanyl w good effectHas had further 15mg midazolam breakthroughWhat do you do to syringe driver?Increase by 200-250mcg dependent on how comfortable she currently looksAdd/ increase midazolam 10mg in syringe driverAnything else?BREAKTHROUGH DOSE!Now on 500mcg/24 hours of fentanyl…. What should breakthrough dose be?1/10- 1/6 total dose, so increase to 50-75mcg breakthrough.
40. What do you say?Daughter says:She needs fluids, you’re starving her to death.She’s suffering, can’t you just end this for her? You wouldn’t put a dog through thisOther great questions you’ve seen?
41. Quick casesMR
42. CasesJean Wilby is a 54 year old female, metastatic colon cancerPeritoneal mets, Liver mets. Declining further treatment, wanting comfort care.Presents with Small Bowel ObstructionUsual meds: Targin 40mg BD, Metoclopramide 10mg TDS, Oxynorm 10mg TDS PRN, dexamethasone 2mgManagement?
43. Initial Management?Analgesia?What would you choose?Drug/sRouteFrequencyBreakthroughs?Antiemetic?What would you choose?Drug/sRouteFrequencyAnything else?
44. So, 80mg oral oxycodone = morphine oral 120mgThen morphine 120mg = morphine 40-60mg SCThen ?dose reduction given opioid titration
45. Actually…. eGFR comes back at 14……Analgesia?What would you choose?Drug/sRouteFrequencyAntiemetic?What would you choose?Drug/sRouteFrequency
46. So, 80mg oral oxycodone = morphine oral 120mgThen morphine 120mg oral = hydromorphone 24mg oralThen hydromophone 24mg oral = hydormophone 8mg SCThen ?dose reduction given opioid titration
47. Jean passes away 48 hours laterYou are paged to verify death…Family are in the room?what’s your experience to date??what’s you approach?
48. Self CareIt’s okay to be sad when your patient diesHonour their life by acknowledging and accepting your emotional reaction.Take some time-out in the loo Go for a walk and think about them after work. It’s okay to do this.Debrief with your reg, consultant, mentor, mates, carol etc.If your patient dies when you are not on?Reflect on how they died. Reflect on what you/your team may have done better, not as self-flagellation, but to learn and growReflect on how YOU would like to die. What is your ideal death
49. TAKE HOMEEND OF LIFE CARE PRESCRIBING… think:PainAlready on opioid?- convert it!Renal function?N+VSOBAgitationNoisy breathingDry MouthCOMMUNICATION TIPS for end of life careWatch these discussions as much as you can!Try and watch pall care’s discussions if you can!
50. You only get to die once… make it a good one.