Transcript good death bad death

5 mins on last days of life
and palliative care
emergencies !
Dr. Ros Taylor
Hospice Director
Hospice of St. Francis Berkhamsted
June 2012
Know who to ring !!!
Know where the resources are !
• Mount Vernon Cancer Network Advice
01923 844281
• Hospices….open all hours
• Peri-patetic Marie Curie Nurse
• OOH District Nurses
Last moments of life
• Precious
• Very symbolic to be together
• Hours at bedside - focus on
separation and memories
Acknowledge death is near
• Fundamental to good management
 Allows symptom control and decisions
 Allows final business and acceptance
• If ignore closeness to death
No
care of dying
Inappropriate treatment
Surprise Question
“ would I be surprised if
this patient died in
………..a few days ??”
Anticipate
We can see the
future…..often
Clinical intuition
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Declining mobility
Distracted and distant
Breathless
Difficulty swallowing
Circulation changes
PEOPLE KNOW !!
Limit treatment to :
• Analgesia
s/c diamorphine or morphine
• Sedation if needed
s/c midazolam or levomepromazine
• Anticholinergic
s/c glycopyrronium or hyoscine
Just in Case Boxes
• 3-5 days of
–Analgesia
–Sedation
–Drying agent
–Anti-nausea
Stopping medication
• Stop futile medication - treat
symptoms only
• If unable to swallow - use
parenteral route
Syringe drivers
• When to use
Unable
to take oral medication
Nausea and vomiting
Dysphagia
Unconscious
• What to use
Fentanyl in the last days
• Keep patch on at same dose death
• Add extra analgesia as morphine in a
driver
The Pain of it all
Managing terminal pain
Continue analgesia until death
If not swallowing
then s/c infusion of diamorphine with 1/3 of
previous oral morphine dose
Breakthrough pain
 Use sixth of 24hr opioid dose
If not had opioids
 Then 10 - 20mg diamorphine s/c per 24 hrs
 Plus anti-emetic
Terminal Dyspnoea
INSPIRE
EXPIRE
Powerful words
When midazolam fails
• Short acting 1-3 hrs
• amnesic not analgesic
• in some people acts like alcohol
– increase agitation and aggression
• Alcohol and benzo use affects its activity
• try Nozinan or Phenobarbitone
Terminal restlessness
• Look for reversible cause
Bladder, bowel, pain, hypoxia
• Best drug is midazolam
 2.5mg – 5mg s/c midazolam
 20
mg++ per 24 hrs midazolam
 Or lorazepam SL
Sedation
“If you want to die in
your sleep you have
to sleep first..”
Liverpool Care Pathway for
the Dying
?? Stairway to Heaven
Or
?? Improve everyones care
to a minimum standard
Know who to ring !!!
Know where the resources are !
• Mount Vernon Cancer Network Advice
01923 844281
• Hospices….open all hours
• Peri-patetic HUC Marie Curie Nurse
• OOH District Nurses