end of life care contain both hospice care and palliative care. 10-20% of the ICU.

1. End of life care
Presented by
Pankaj
Nurse Practitioner 2nd
yr
Moderator
Dr. sushant Khanduri
Associate professor

2. END OF LIFE CARE
Palliative Care
Making life as easy as possible for patients
and families living with serious illness
Hospice care
hospice care is given when there is life
expectancy of 6 month or less

3. End of Life in the ICU
 10-20% of all ICU patients die
 Often illnesses are unanticipated – little
previous discussion of illness with family
 Prognostication variable
 Culture of aggressive treatment
 Patients not generally able to
participate

4. Five Most Common Symptoms
 Pain
 Nausea/vomiting
Breathlessness
 Weight loss
 Weakness / fatigue

5. Basics of Pain Management
 Use a pain scale
 WHO pain ladder
 Use standing doses, not PRN
 Always have a breakthrough pain plan
10% of daily opioid dose q 1-2 h
Reassess dosage needs daily

6. Assessment of Pain
PQRST
P = Provoking/Palliating factors
Q = Quality in patient’s own words
R = Radiates
S = Severity
T = Time
Recommended instruments:
• McGill Pain Questionnaire (MPQ) and its short form
(SF-MPQ)

8. WHO 3-step
Ladder
1 mild (1-3)
2 moderate
(4-6)
3 severe (7-10)
Morphine
Hydromorphone
Methadone
Levorphanol
Fentanyl
Oxycodone
± Adjuvants
A/Codeine
A/Hydrocodone
A/Oxycodone
A/Dihydrocodeine
Tramadol
± Adjuvants
ASA
Acetaminophen
NSAIDs
± Adjuvants

9. Neuropathic Pain
 Tricyclic Antidepressants (1 in 3 pts
respond)
◦ Desipramine, other TCA’s, venlafaxine
◦ Use limited by CV adverse effects
 Gabapentin/Pregabalin (1 in 4 patients
respond)
◦ usual effective dose 900–1800 mg / d; max may be > 3600 mg / d
◦ minimal adverse effects
◦ drowsiness, tolerance develops within days
• Systemic administration of local anesthetics
• Lidocaine or mexiletine effective in 30 RCT’s
• Combination may be the most effective
Brunnhuber, K., Nash, S., Meier, D.E., et al (2008

10. Bone pain
Metastasis to bone
◦ 70% of pt with prostate, breast CA
◦ 30% of pt with thyroid, lung, bladder CA
 Multidisciplinary approach, including:
 Analgesics: opioids, NSAIDs
 Disease modifying therapy (chemotherapy, hormone
therapy)
 Corticosteroids
 Bisphosphonates
 Radiopharmaceuticals (strontium, samarium)
 External beam radiation
 Orthopedic intervention
 External bracing

11. Depression
Loss of social position,
job, prestige, income
Loss of role in family
Insomnia, chronic
fatigue Sense of
helplessness
Disfigurement
Anger
Bureaucratic bungling
Delays in diagnosis
unavailable physicians
uncommunicative
physicians Failure of therapy
Friends who do not visit
Total
Pain
Anxiety
Fear of hospital or nursing home
Fear of pain
Worry about family and
finances Fear of death
Spiritual unrest, uncertainty about future
Physical pain
Other symptoms
Adverse effects of treatment
O'Neill, B., Fallon, M. BMJ 1997, 315p. 801-80

12. Nausea/Vomiting
• Patients with cancer
• 13-17% of terminally ill cancer patients in the last
1-2 weeks of life
• 6-68% of all patients with cancer
 Patients with other illnesses:
◦ AIDS: 43% to 49% of patients
◦ Heart disease: 17% to 48% of patients
◦ Renal disease: 30% to 43% of patients
 Assessment: simple visual analogue
scales or numerical rating scales

13. Cause Drug Examples
V – Vestibular Cholinergic
Histaminic
Anticholinergic
Antihistaminic
Scopolamine
Promethazine
Diphen-
hydramine
O – Obstructive Cholinergic
Histaminic
5HT3
Drugs stimulating the
myenteric plexus
Senna products
M- Motile
(dysmotility of
upper gut)
Cholinergic
Histaminic
5HT3
Prokinetics
(stimulating 5HT4
receptors)
Prokinetics, metoclo-
pramide
I –
infectious/inflam-
matory
Cholinergic
Histaminic
5HT3
Neurokinin 1
Anticholinergic
Antihistaminic
5HT3 antagonists
Neurokinin 1 ant.
Anti-inflammatory
Scopolamine
Promethazine
Diphenhydramine
Odansetron
Apprepitant
Corticosteroids
Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)See handout for doses, cost
Treat anxiety if present
Management of nausea and vomiting

14. DYSPNEA
 Prevalence
◦ 17-30% of patients living with cancer
◦ 90-95% of end-stage COPD patients
◦ 60-88% of end-stage heart disease
patients
 Increasingly common as the end of life
approaches
 Best assessment is patient report

15.  Recent ACP guidelines show evidence
supports treatment with:
◦ Oxygen for hypoxemia
 Strong evidence for COPD & exercise
◦ Opioids
 Theoretical effect of respiratory
depression not supported by the
literature
◦ Beta-agonists for dyspnea from COPD
Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med.
2008;148:141-146

16. Fatigue
• Approximately 40% of cancer patients
experience fatigue at the time of diagnosis
• Worse during or after chemotherapy
• Higher than 75% in patients with
advanced cancer
• Common with COPD, heart failure
• Multifactorial
• Best evaluated by self-assessment
measures
• No gold standard measurement available

17. Management of Fatigue
 Evidence supports use of:
◦ Psychological, psychoeducational interventions
(small)
◦ Methylphenidate – small, significant improvement
• Exercise - small improvement
 Energy conservation, activity management -
small but significant effect
 No effect: progestational steroids,
paroxetine, or multivitamins.
 Insufficient data to recommend any specific
complementary therapies
Brunnhuber, K., Nash, S., Meier,
D.E., et al (2008)

18.  Promote energy conservation
 Evaluate medications
 Optimize fluid, electrolyte intake
 Permission to rest
 Clarify role of underlying illness
 Educate, support patient, family
 Include other disciplines

19.  Dexamethasone
◦ 4mg PO once daily
◦ feeling of well-being, increased energy
◦ effect may wane after 4-6 weeks
◦ continue until death
 Methylphenidate
◦ 5mg PO q 8AM and q noon
◦ May increase up to 20mg daily
 Do not give after 2pm to avoid interfering with sleep

20. Anorexia/Cachexia
• Prevalence: 70% of patients with
advanced cancer
• Best assessment is patient report
• Treatments:
• Corticosteroids
• Orally consumed supplements
• Parenteral nutrition
Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)

21. NUTRITION
• High calorie diet
• High protein diet
If patient cannot take orally.
• Try enteral feeding( BEST FEEDING )
• And lastly parenteral nutrition

22. Management
 Family education is key
 Tailor diet to patient preferences
◦ Fresh fruit
 Melon, grapes
◦ Things that are cold and sweet
 Ice cream
◦ Lemon drops, zinc lozenges for bad taste in mouth
◦ Most patients do not want dairy, fried foods
 Manage grief, disappointment about change in diet
 Encourage socializing at meal times even if patient
does not want to eat

23. Depression
 Recent ACP Guidelines:
◦ Physicians should screen for and treat
depression in patients facing end-of-life
◦ Evidence supports use of TCA’s and
SSRI’s
◦ Psychosocial interventions also effective
 Some providers will use methylphenidate in
patients with very short life expectancy
Qaseem, A, Snow, V., Shekelle, P, et al. AnnIntern Med. 2008;148:141-146

24. Delirium
• Prevalence:
• 20% to 30% of people with cancer, COPD and
end-stage liver disease in SUPPORT
• 26% to 44% in terminal cancer
• 83% in people during their final days.
• Assessment:
• Confusion Assessment Method (CAM)
• Memorial Delirium Assessment Scale
(MDAS)
• Treatment in the terminally ill is difficult
• Prevention is key

25. • Drugs are the most common cause of
delirium
• reduction and possibly withdrawal of
anticholinergic and psychoactive drugs
• opioid dose reduction and/or rotation (usually
at an equi analgesic dose with a reduction of
20% to 30%)
• Newer antipsychotics no better than
haloperidol

26. Pain Ratings For 16 Common Hospital Procedures For 165 Subjects
 Urethral catheter
 Mechanical restraints
 Movement from bed to chair
 IM/SC injection
None
 IV catheter
 Chest x-ray
 Vitals signs
 Transfer to a procedure
 Waiting for a test or procedure
 PO medications
severe
 Arterial blood gas
Moderate
 Central line placement
 Nasogastric tube
 Peripheral IV insertion
 Phlebotomy
Mild
Morrison et al, JPSM 1998

27. EUTHANASIA
• Euthanasia is described as the deliberate and
intentional killing of a person for the benefit
of that person in order to relieve him from
pain and suffering
• The term ‘Euthanasia’ is derived from the
Greek words which literally means “good
death” (Eu=Good; Thanatos=Death).

28. Types
• Euthanasia can be categorized into two types-
active and passive
(a)Active Euthanasia- When a person directly
and deliberately does something which results
in the death of patient.
• It is considered crime in many country and in
India but Netherlands, Belgium, Switzerland is
sanctioned by the passage of “Termination of
Life on Request and Assisted Suicide (Review
Procedures) Act”

29. • Euthanasia can be further classified as
‘voluntary’ where euthanasia is carried out at
the request of the patient and ‘non-voluntary’
where the person is unable to ask for
euthanasia (perhaps because he is
unconscious or otherwise unable to
communicate), or to make a meaningful
choice between living and dying and a
surrogate person takes the decision on his
behalf.

30. Cases
• Now we shall discuss two important
judgments: Airedale case from the House of
Lords, UK and Aruna Shanbaug case from
Supreme Court of India giving us a fair idea
regarding the evolution of the laws pertaining
to Passive Euthanasia in India and the world.
• irreversible coma or Permanent Vegetative
State are indication of ethunasia

31. Aruna Shanbaug

32. Tony bland

33. DNR (Do Not Resuscitate)
DNR (Do Not Resuscitate) is a clear concept in
most developed countries. It involves not
initiating resuscitation in the event of a
cardiac or respiratory arrest.

34. CANDIDATES FOR DNR
• Where life sustaining treatment is likely to be
ineffective or futile.
• -Where patient has prolonged
unconsciousness which is unlikely to recover.
• -Where patient has a terminal condition for
which there is no definitive therapy.
• -Where patient has a chronic debilitating
disorder where burden of resuscitation far
outweighs the benefits.

35. NOT THE CANDIDATES FOR DNR
• Patient is unable to pay for advanced care.
• Where the outcome is doubtful (may or may
not improve situation).
• Where there is conflicting opinion among the
family members.
• Where responsible next of kin is not available
for discussion.
• Where written consent is not available.

36. DNR procedure
• Clear airway
• Inotropic support
• Provide Oxygen
• Position for comfort
• Splint
• Control bleeding
• Provide pain medication
• Provide emotional support
• nutrition

37. Not done in DNR
• Perform chest compressions
• Insert advanced airway
• Administer Cardiac resuscitation drugs
• Provide ventilator assistance including non
invasive ventilation
• Defibrillate

38. CARE OF DEAD BODY
DEAD BODY CARE
After death the body undergoes many physical
changes. So care must be provided as early to
prevent tissue damage /disfigurement of body
parts.

39. Purpose of dead body care
1. To prepare the body for the morgue.
2. To prevent discoloration or deformity of the
body.
3. To protect the body from post mortem
discharge.

40. 1. Check orders for any specimens
2. Ask for special requests to family (eg: shaving , a
special gown , Bible in hand )
3. Remove all equipments , tubes , supplies and
dirty linens.
4. Cleanse the body thoroughly , apply clean
sheets
5. Brush and comb the hairs
6. The eyelids are closed and held in place for a
few seconds , so they remain closed.
7. Dentures should be in the mouth to maintain
facial alignment.

41. 8. Mouth should be closed.
9. Remove all the ornaments.
10. Absorbent pads are placed under the buttocks to take
up any feaces and urine released because of muscle
sphincter relaxation
11. All the orifices should be closed.
12. Cover with a clean sheet up to the chin.
13. Spray a deodorizer to remove unpleasant odor.
14. Apply name tag ( wrist , right big toe)
15. Allow the family members to view the dead body
16. The body is wrapped in a large piece or plastic or
cotton material used to enclose a body after death.
Identification is then applied outside of the wrapper.

42. 17. Hand over all the belongings to the relatives.
18. Do complete documentation in the nursing notes.
Time of death and actions taken to prevent the
death. Who pronounced the death. Any organ
donation Personal articles left on the body Personal
items given to family Time of discharge and
destination of the body Location of name tags on the
body Special request by family
19. Hand over the dead body to the relatives / sent to
the mortuary.

43. Thank you