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How to care for the dying


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A quick review of the signs, symptoms, and basic treatment for the dying.

Published in: Health & Medicine
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How to care for the dying

  1. 1. Clinical Pearls:How to care for the dying patientSuzana Makowski, MD MMM FACP
  2. 2. • Quick review of palliative care• Recognizing hope at end-of-life• How to assess patient• How to manage symptomsOverview
  3. 3. Wanting more pain relief More physician contact Wanting more respectFamily rating EOL care
  4. 4. 40-70%die inpain60%suffer35%loose lifesavings
  5. 5. • Do you want us to do everything, or just…?• If your heart stops, do you want us to use chest compressions to get it started again or to keep you comfortable?• Your choice is either to have this PEG and maybe live for months, or to not have the PEG and go to hospice and die in a few days…• You mean you don’t want us to intubate you? Not even a breathing machine (BiPAP)? Then what do you want us to do? -Things I have heardWe don’t know what to offer
  6. 6. • Withdrawal from outside world • Withdrawal from family • Increased sleeping • Gradual decreases in eating1-3 months prior to death
  7. 7. • Lower blood pressure• Changes in heart rate • The relief of suffering, it• Temperature fluctuations would appear, is considered one of the primary ends of• Increased perspiration medicine by patients and lay• Breathing fluctuations persons, but not by the medical profession.• Skin color changes• Further withdrawal, -Eric Cassell perhaps confusionHours to days prior to death
  8. 8. • Increased risk for wounds• Requesting turns, appropriate bed• Check skin integrity • Barrier creams • Wound care • MoisturizerSkin
  9. 9. • Loss of sphincter control• Consider catheter – part of goals of care discussion• Meticulous skin care – requires increased nursing checks, turns, etc.• Puts patient at increased risk of skin breakdown• Distressing to familyIncontinence
  10. 10. • Prevalence: 50% moderate to severe pain• Evaluation of pain: verbal patient, vs. non-verbal • Pain vs. delirium• Treatment of pain: • Opioids • Non-opioid analgesics • Non- pharmacologic interventions Pain
  11. 11. • Assess difference between dyspnea and normal changes in breathing • Dyspnea: subjective, history • Normal pattern changes: Δ tidal volume, Cheyne-Stokes.• Educate family and caregivers: address myths • “suffocating” • Decrease in oxygen = sufferingBreathing
  12. 12. • Prevalence: as high as 70%• Which diagnoses?• Treatment options: • Opioid: morphine, oxycodone, hydromorphone, fentanyl* • Chlorpromazine (Thorazine) • β-agonist • Non-pharmacologic: fan, oxygen, stress-reduction (music, etc.)Breathlessness
  13. 13. • Zofran is NOT the be-all-and-end-all• Know your pharmacology and pathophysiology!Nausea
  14. 14. • Cause: wasting of retro-orbital fat pad, causing orbit to fall within orbital socket• Treatment: • Educate family and nursing • Provide moisture to conjunctiva: • Artificial tears • LacrilubeEyes – unable to close
  15. 15. • Associated with loss of ability to swallow and loss of gag.• Gurgling, rattling• Treatment: • Educate family • Medical intervention: Glycopyrrolate, hyoscine hydrobromide (Scopolamine) • Non-pharmacologic: Repositioning, postural drainage. • Suction is not effectiveSecretions “death rattle”
  16. 16. • Medical management you have been prescribing still applies. • Opioids may be helpful for dyspnea and painAvoid morphine in renal failure – fentanyl, methadone, perhaps oxycodone preferable • Constipation is the opioid only side effect one does not gain tolerance to give pro-motility (softener not enough) • Respiratory suppression is due to overdose, not appropriate dose • Terminal secretions: repositioning, stop artificial feeding and hydration, anticholinergics – avoid suctioning  why? • Nausea: often due to dopamine receptor in chemoreceptor trigger zone haloperidol = metoclopromide - promotility • Delirium: common causes still apply and may be reversible! – constipation, urinary retention, infection, pain, medications Assuring good symptom control Some pearls
  17. 17. Psychological Symptoms“Dying is not primarily a medical condition, but a personally experienced, lived condition.” William Bartholme, MD. 1997. Kansas City.
  18. 18. • There is more we can do• Assure non-abandonment• Comfort care is not “just” anythingSummary
  19. 19. • Sir William Osler: “ ““ • Eric Cassell: “
  20. 20. Thanks to many, including:Thank you (Sept 1, 2009), my friends and family
  21. 21. • EPEC (Education on Palliative & End-of-Life Care)• Lois Green Learning Community• Get Palliative:• Pallimed ConnectHow to learn more