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Care of the imminently dying patient

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Presented to HPM Fellowship July 2010. Has handout also uploaded.

Presented to HPM Fellowship July 2010. Has handout also uploaded.

Published in: Health & Medicine

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  • Photo Credit “ The Passage of Time” by ToniVC http://www.flickr.com/photos/tonivc/2283676770/ Graphs How do you know when you are there? How do you diagnose dying beyond ‘everyone is dying… What is a potentially reversible process and what is the inevitable decline Working with ranges (Min - Hrs – Dys – Wks) The rally See my other talk on Prognosis
  • Photo Credit “ The Passage of Time” by ToniVC http://www.flickr.com/photos/tonivc/2283676770/ Working with ranges (Min - Hrs – Dys – Wks) Palliative Performance Scale Palliative Prognostic Index
  • Photo Credit “ The Passage of Time” by ToniVC http://www.flickr.com/photos/tonivc/2283676770/ Working with ranges (Min - Hrs – Dys – Wks) Palliative Performance Scale Palliative Prognostic Index
  • Photo Credit “ The Passage of Time” by ToniVC http://www.flickr.com/photos/tonivc/2283676770/ Graphs How do you know when you are there? Working with ranges (Min - Hrs – Dys – Wks) The rally See my other talk on Prognosis
  • To be reviewed in the prognosis section
  • Minimal impact through management Few studies of symptom control in the last few days of life. All observer survey Secretion control particularly poor Maximal impact through expectations Focus on education and counseling Preparations of what may or may not happen Family and patients with few experiences with actively dying patients Sailor analogy Controlling the sea quote Some situations where all symptoms cannot be controlled; don’t promise the moon Don’t promise to control the pain, delirium etc. Promise to closely involved and always trying.
  • Minimal impact through management Few studies Maximal impact through expectations Sailor analogy Some situations where all symptoms cannot be controlled; don’t promise the moon
  • Time and logistics Physical tasks Financial costs Emotional burdens and mental health risks Physical health risks http://photooftheday.hughcrawford.com/
  • Time and logistics Can I run home to get a new change of clothes? Will Bill get here from Denver in time to see him? I don’t want to be alone, can we make sure someone is always with me? Physical tasks Lifting, wiping, falling, adjusting, touching, cleaning, massaging, bathing Financial costs Hospice is a great benefit, but they aren’t there all the time, time off work, travel costs, hiring aides, missed opportunities, unnecessary treatments Emotional burdens and mental health risks Early grief, depression, anxiety, requests for hastened death, delirium, loss of communication Physical health risks mortality (grief effect and relief effect – JAMA study), morbidity, medication adherence, altered eating and sleeping habits http://photooftheday.hughcrawford.com/
  • Time and logistics Can I run home to get a new change of clothes? Will Bill get here from Denver in time to see him? I don’t want to be alone, can we make sure someone is always with me? Physical tasks Lifting, wiping, falling, adjusting, touching, cleaning, massaging, bathing Financial costs Hospice is a great benefit, but they aren’t there all the time, time off work, travel costs, hiring aides, missed opportunities, unnecessary treatments Emotional burdens and mental health risks Early grief, depression, anxiety, requests for hastened death, delirium, loss of communication Physical health risks mortality (grief effect and relief effect – JAMA study), morbidity, medication adherence, altered eating and sleeping habits http://photooftheday.hughcrawford.com/
  • Time and logistics Can I run home to get a new change of clothes? Will Bill get here from Denver in time to see him? I don’t want to be alone, can we make sure someone is always with me? Physical tasks Lifting, wiping, falling, adjusting, touching, cleaning, massaging, bathing Financial costs Hospice is a great benefit, but they aren’t there all the time, time off work, travel costs, hiring aides, missed opportunities, unnecessary treatments Emotional burdens and mental health risks Early grief, depression, anxiety, requests for hastened death, delirium, loss of communication Physical health risks mortality (grief effect and relief effect – JAMA study), morbidity, medication adherence, altered eating and sleeping habits http://photooftheday.hughcrawford.com/
  • Time and logistics Can I run home to get a new change of clothes? Will Bill get here from Denver in time to see him? I don’t want to be alone, can we make sure someone is always with me? Physical tasks Lifting, wiping, falling, adjusting, touching, cleaning, massaging, bathing Financial costs Hospice is a great benefit, but they aren’t there all the time, time off work, travel costs, hiring aides, missed opportunities, unnecessary treatments Emotional burdens and mental health risks Early grief, depression, anxiety, requests for hastened death, delirium, loss of communication Physical health risks mortality (grief effect and relief effect – JAMA study), morbidity, medication adherence, altered eating and sleeping habits http://photooftheday.hughcrawford.com/
  • Time and logistics Can I run home to get a new change of clothes? Will Bill get here from Denver in time to see him? I don’t want to be alone, can we make sure someone is always with me? Physical tasks Lifting, wiping, falling, adjusting, touching, cleaning, massaging, bathing Financial costs Hospice is a great benefit, but they aren’t there all the time, time off work, travel costs, hiring aides, missed opportunities, unnecessary treatments Emotional burdens and mental health risks Early grief, depression, anxiety, requests for hastened death, delirium, loss of communication Physical health risks mortality (grief effect and relief effect – JAMA study), morbidity, medication adherence, altered eating and sleeping habits http://photooftheday.hughcrawford.com/
  • http://en.wikipedia.org/wiki/Image:Lines_Apophysis_Fractal_Flame.jpg Systems Based Decline Helps understand prognostication Understanding physiology Somewhat theoretical Impacts the role of the physical
  • http://www.flickr.com/photos/chickenlump/2038512161/ Exam of the Dying Patient Consider limiting to only the areas that need examining for prognostic or comfort purposes.
  • Photo by Pear Biter http://www.flickr.com/photos/pearbiter/2101587541/‘ Weakness/Asthenia Progressing to Bedbound, degree of changes over time Fatigue Lack of stamina not necessarily the lack of strength Biggest treatment – acceptance Avoiding excessive activities Fever / Hypothermia Not necc sign of infection, autonomic disregulation
  • Eyes & OroPharyngeal Open Eyes / Dry Eyes Dilation vs. constriction atropine vs. opioid Slowed pupilary reflexes
  • Oral anatomy, discuss salivary gland function Sublingual, submandibular, parotid Xerostomia Not secondary to dehydration loss of autonomic function anticholinergic effect of many medications Good frequent mouth care (family teaching point) Avoiding thrush Avoiding bleeding Caring activity IVF don’t treat xerostomia Artificial salivas (a tough sell for some) Pilocarpine, smelling citrus, massage glands, chew gum (exhausting) Oropharyngeal Secretions Atropine, other anticholinergics Contribution of SL medications Loss of normal clearing mechanisms Dysphagia – Swallowing techniques, pleasure feeding Skeletal and smooth muscle, autonomic nervous system Phases - oral preparatory, oral transport, pharyngeal, and esophageal Wiki entry for pharyngeal - In this phase, the bolus is advanced from the pharynx to the esophagus through peristalsis . The soft palate is elevated to the posterior nasopharyngeal wall, through the action of the levator veli palatini. The palatopharyngeal folds on each side of the pharynx are brought close together through the superior constrictor muscles, so that only a small bolus can pass. Then the larynx and hyoid are elevated and pulled forward to the epiglottis to relax the cricopharyngeus muscle. This passively shuts off its entrance and the vocal cords are pulled close together, narrowing the passageway between them . This phase is passively controlled reflexively and involves cranial nerves V, X (vagus) , XI (accessory) , and XII (hypoglossal)
  • http://flickr.com/photos/bunchofpants/53127137/ Bunchofpants Dysgeusia – Education Anorexia – Major family education point here – GI shut down – industrial analogy Cachexia – body image issues Decreased Fluid Intake – another major family education point Incontinence - dignity
  • Anorexia – Major family education point here GI shut down – industrial analogy Lack of appetite No starving if no hunger exists Find alternative caring options Cachexia body image issues Decreased Fluid Intake another major family education point refer back to mouth care IVF may be considered for a trial, but not reccommended since they cause their own problems. Bowel Incontinence Dignity, Care giving issues
  • Add heart light graffiti image here Hypotension Hypovolemic Cardiogenic Septic Poor cap refill, cyanosis, mottling, edema Brady / Tachycardia possible sign of distress body adjustment Implantable Devices think ahead about deactivation Don’t forget about blood pressure meds Major prognostic value in imminent death Can be fooled with variation
  • http://flickr.com/photos/duncan/104321008/ Renal Failure adjusting medications Incontinence dignity Changes in Urine Family keenly aware What IS floating in the urine?
  • http://www.egms.de/figures/journals/cto/2006-5/cto000028.f8.png Tachypnea distress versus metabolic acidosis Apnea prognostic sign or long standing problem Dyspnea pt centered subjective assessment vs. work of breathing Cheyne-Stokes – fast deep with apneic epsidoes Kussmaul’s – deep not fast, hypervent Oxygen?
  • http://flickr.com/photos/marylane/520905761/ Photo by MaryLane Turning balance with pt comfort Wound Care balance with pt comfort goal not necc to heal Mottling prognostic?
  • http://flickr.com/photos/gremio/182654556/ Photo by gremionis Communication of prime importance to pt and family can be source of frustration loss of dignity Can they hear? Probably not, but it may be important to talk (or not talk) for social reasons Delirium Can be very difficult, common and dignity issue, manage through expectations and medications Decreased Level of Consciousness Seizure May need to change medications Anxiety
  • http://image.guim.co.uk/sys-images/Technology/Pix/pictures/2007/09/12/hospital460.jpg Home – often preferred Hospice Facility Hospital +/- Palliative Care Unit Nursing Home Goal is not always get them home as articles may tell you.
  • Home – often preferred Hospice Facility Hospital +/- Palliative Care Unit Nursing Home Goal is not always get them home as articles may tell you.
  • http://flickr.com/photos/johnivara/2143590802/ Uncontrolled symptoms, think pain other then physical
  • http://flickr.com/photos/garrettc/2424375997/ Prognosis / Goal Mismatch If not aligned then change the medications Pill Dysphagia - Think ahead for other options Alternate Routes PR is not the only option Topical medications – eh.
  • http://flickr.com/photos/lawrence_evil/588771342/
  • Transcript

    • 1. Care of the Imminently Dying Patient July 8 th , 2010 Christian Sinclair, MD Kansas City Hospice & Palliative Care
    • 2. Prognostication of the Terminal Phase
    • 3. Working with Ranges - Minutes
    • 4. Working with Ranges - Hours
    • 5. Working with Ranges - Days
    • 6. Death Trajectories
      • Sudden Death
      • Death from Acute Illness
      • Death from Chronic Illness
      • After Withdrawal of Life Support
    • 7. Scales
      • Palliative Performance Scale
      • Palliative Prognostic Index
      • Links available from:
        • prognosis.pallimed.org
        • EPERC Fast Facts
    • 8. The Rally
    • 9. What to Manage vs. What to Expect Expect Manage
    • 10. What to Manage vs. What to Expect Expect Manage
    • 11. Transforming from Patient-Centered Care to Family-Centered Care
    • 12. Time and logistics Time & Logistics
    • 13. Time and logistics Time & Logistics Physical Tasks
    • 14. Time and logistics Time & Logistics Physical Tasks Financial Costs
    • 15. Time and logistics Time & Logistics Physical Tasks Financial Costs Emotional Burden
    • 16. Time and logistics Time & Logistics Physical Tasks Financial Costs Emotional Burden Physical Risks
    • 17. Systems-Based Decline
    • 18. Examination of the dying patient
    • 19. Constitutional Weakness & Fatigue Fever & Hypothermia
    • 20. Eyes & Oropharyngeal
    • 21.  
    • 22.  
    • 23. Gastrointestinal
      • Anorexia – Major family education point here – GI shut down – industrial analogy
      • Cachexia – body image issues
      • Decreased Fluid Intake – another major family education point
      • Incontinence - dignity
    • 24. Cardiovascular
      • Hypotension
        • Hypovolemic
        • Cardiogenic
        • Septic
          • Poor cap refill, cyanosis, mottling, edema
      • Brady / Tachycardia
        • possible sign of distress body adjustment
      • Implantable Devices
        • think ahead about deactivation
      • Don’t forget about blood pressure meds
      • Major prognostic value in imminent death
      • Can be fooled with variation
    • 25. Renal
    • 26. Pulmonary
    • 27. Skin Care
    • 28. Neurological/Psychological
    • 29. Considerations of Location
    • 30.  
    • 31. Spiritual/Existential Considerations
    • 32. Medication Management
      • Prognosis / Goal Mismatch
        • If not aligned then change the medications
      • Pill Dysphagia
        • - Think ahead for other options
      • Alternate Routes
        • PR is not the only option
        • Topical medications – eh.
    • 33. Unexplained Prolongation of the Terminal Phase
      • No one has really looked at this population but it bears some examination.
    • 34.
      • For a copy of the slides, please email: csinclair@kchospice.org
      • Recommended Reading/ Key References:
      • Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3 rd Ed.
      • EPEC – Last Hours of Living, Module 12, 1999.
      • Ferris FD, von Gunten CF, Emanuel LL. Competency in End-of-Life Care: Last Hours of Life. J of Pall Med. August 2003: 605-613.
      • Plonk WM, Arnold RM. Terminal Care: The Last Weeks of Life. J of Pall Med 8(5): 1042-55