Transcript Guidelines for a Palliative Approach in Residential Aged Care

End of Life Care
Aged care end of life issues
• When does the end of life begin?
• Where should the end of life occur?
• What is best practice end of life care?
• What is needed to support this?
Pain management in end of life
care
• Pain is a symptom that can occur in the last
days of life
• Where pain is a pre-existing symptom,
measures should be in place to ensure
continued effective management during the end
of life
• If pain is not a present problem, an intermittent
(PRN) analgesic is ordered in anticipation of
pain presenting.
Care context
• The end of life goal is that the individual be pain
free
• Regular assessment is needed
• When pain is assessed, ordered analgesia is
administered, and effectiveness determined
• Episodes of pain and its management are
documented
Analgesia considerations
• If more than 3 PRN doses are given in a 24-hour
period:
– regular subcutaneous administration 4 hourly
or a continuous subcutaneous infusion via
syringe driver may be considered.
– if already on regular administration the
dosage should be reviewed
– the PRN order is reviewed in line with
alterations to regular doses
Other pain management issues
• Keep the individual and/or their primary carer
informed about the care strategy
• Ensure that PRN medications are given in
response to pain, or in anticipation of incident
pain (eg, on moving)
• Ensure that the attending doctor is informed of
any inadequacies in the pain management
strategy
Other pain issues (2)
• Remember that any pain experience can be
amplified by psychological and spiritual distress
• Maintaining general comfort measures will
contribute to the overall management of pain
Review
• If the prescribed medications are ineffective a
medical review is indicated.
• Escalating doses of opioids are not commonly
seen in the last days of life, and should be
regarded as an indication for urgent medical
review
• Consult with the specialist palliative care service
if indicated
Pain assessment in advanced dementia
(PAINAD) (Central Coast Adaptation)
0
Breathing
Independent of
vocalisation
Negative
Vocalisation
Facial expression
Body Language
Consolability
1
2
Normal
Occasional laboured breathing.
Short period of hyperventilation
Noisy laboured breathing.
Long period of
hyperventilation.
None
Occasional moan or groan.
Low level speech with a negative
or disapproving quality
Repeated troubled calling
out.
Loud moaning or groaning.
Crying
Smiling, or
inexpressive
Sad. Frightened. Frown
Facial grimacing
Relaxed
Tense.
Distressed pacing. Fidgeting
Rigid. Fists clenched,
Knees pulled up.
Pulling or pushing away.
Striking out
No need to
console
Distracted or reassured by voice
or touch
Unable to console, distract or
reassure
Bibliography
•
Anderson SL. & Shreve ST. 2004 Continuous subcutaneous infusion of
opiates at end-of-life. Annals of Pharmacotherapy. 38(6):1015-23
•
Ellershaw J, Wilkinson S. 2003 Care of the Dying: A pathway to
excellence.
Nauck F, Klaschick E, Ostgathe C. 2000 Symptom Control in the Last
Three Days of Life. European Journal of Palliative Care 7(3): 81 - 84
Regnard C, Hockley, J. 2004 A Guide to Symptom Relief in Palliative
Care
Twycross R, Wilcock A. 2001 Symptom Management in Advanced
Cancer
Wrede-Seaman LD. 2001 Treatment options to manage pain at the end
of life. American Journal of Hospice and Palliative Care 18(2): 89-101,
144
•
•
•
•
Nausea / vomiting in end of life
care
• Nausea is a symptom that may occur in the last
days of life
• The causes of nausea / vomiting in the dying
vary across diseases
Medication
• If nausea / vomiting has been an ongoing
symptom prior to the last days of life then a
regular anti-emetic is ordered together with
PRN (as required) doses.
• If nausea / vomiting is not a present symptom,
then an intermittent (PRN) anti-emetic is
ordered in anticipation of nausea / vomiting
presenting.
Care context
• The pathway goal is that the individual has no
episodes of nausea / vomiting
• Nausea / vomiting is assessed regularly
• When an episode of nausea / vomiting occurs,
the ordered anti-emetic is administered, and
effectiveness determined
• Each episode is recorded in the progress notes
Review
• If the prescribed medications are ineffective a
medical review is indicated.
• Consult with the specialist palliative care service
if indicated
Bibliography
• Haughney A. 2004 Nausea & vomiting in end-stage cancer.
American Journal of Nursing 104(11):40-8
• Regnard C, Hockley J. 2004 A Guide to Symptom Relief in Palliative
Care
• Woodruff, R. 2004 Palliative Medicine
• Cherny NI. 2004 Taking care of the terminally ill cancer patient:
management of gastrointestinal symptoms in patients with advanced
cancer. Annals of Oncology 15(Suppl 4):iv205-13
Respiratory problems in end of
life care
• Two respiratory symptoms that can occur during
the dying process are excessive respiratory
secretions and dyspnoea.
Respiratory secretions
• If excessive respiratory secretions are not a
present symptom, an intermittent (PRN)
antimuscarinic agent is ordered in anticipation of
this symptom occurring.
• Hyoscine hydrobromide is a suggested
medication, unless contraindicated.
• Repositioning can be effective in managing
secretions.
• Suctioning is not usually used.
Respiratory secretions
• The noise associated with respiratory
secretions can be a source of distress for
carers, and additional explanation and
reassurance may be indicated.
• In conscious patients glycopyrrolate (Robinal)
or hyoscine butylbromide (Buscopan) may be
preferred.
Respiratory distress
• Respiratory distress is managed in response to
the underlying cause.
– Morphine (subcutaneous injection) has been
shown to reduce dyspnoea without significant
respiratory depression
– Anxiolytics (benzodiazepines) may reduce
dyspnoea, especially where anxiety/ fear is a
contributing factor.
– Oxygen may relieve the dyspnoea associated
with hypoxia
Care context
• The care goal is that the individual has no
episodes of respiratory distress or excessive
respiratory secretions.
• Respiratory symptoms are assessed regularly.
• When an episode occurs, the ordered
medication (or intervention) is administered, and
effectiveness determined.
• Episodes are documented in the progress notes.
Review
• If the prescribed medications are ineffective a
medical review is indicated.
• Consult with the specialist palliative care service
if indicated
Bibliography
• Furst CJ, Doyle D. 2004 The Terminal Phase, in Doyle et al Oxford
Textbook of Palliative Medicine (3rd Ed)
• Jennings AL, Davies AN, Higgins JPT, Broadley K. 2001 Opioids for
the palliation of breathlessness in terminal illness. The Cochrane
Database of Systematic Reviews, Issue 3. Art. No.: CD002066. DOI:
10.1002/14651858.CD002066
• O'Donnell V. 1998 Symptom management. The pharmacological
management of respiratory tract secretions. International Journal
of Palliative Nursing 4(4): 199-203.
• Wildiers H, Menten J. 2002 Death rattle: prevalence, prevention and
treatment. Journal of Pain and Symptom Management 23(4): 310-7
Agitation / anxiety / restlessness
in end of life care
• Agitation / anxiety / restlessness are a group of
symptoms that may occur in the last days of life
• The possible causes of agitation / anxiety /
restlessness in the dying are many, and the
exact cause will be evident in about 50% of
cases.
Agitation / anxiety / restlessness
• Possible causes of agitation / anxiety /
restlessness include:
• physical discomforts (eg. pain, full bladder,
pressure areas)
• anxiety and existential distress
• drug toxicity, hypoxia
• metabolic imbalance
• Where a clearly reversible cause is identified,
intervention to reverse the cause is appropriate
Agitation / anxiety / restlessness
• If agitation / anxiety / restlessness is not a
present problem, an intermittent (PRN) anxiolytic
is ordered in anticipation of agitation / anxiety /
restlessness presenting during the end of life
period
Agitation / anxiety / restlessness
• If more than 3 PRN doses are given in a 24-hour
period a more regular administration should be
considered.
• Alternatively the substitution of a regularly
administered long acting benzodiazepine (eg
Clonazepam) may be appropriate.
Care context
• The care goal is that the individual has no
episodes of agitation or restlessness
• Agitation / anxiety / restlessness is assessed
regularly
• When an episode of agitation / anxiety /
restlessness occurs, the appropriate nursing
intervention or medication is administered, and
effectiveness determined.
• Each episode is recorded in the progress notes
Review
• If the prescribed medications are ineffective a
medical review is indicated.
• Consult with the specialist palliative care service
if indicated.
• Occasionally agitation may be refractory to
standard drug treatment.
Bibliography
• Brajtman S. 2003 The impact on the family of terminal restlessness
and its management. Palliative Medicine 17(5): 454-60
• Ellershaw J. Wilkinson S. 2003 Care of the Dying: A pathway to
excellence
• Regnard C, Hockley J. 2004 A Guide to Symptom Relief in Palliative
Care
• Twycross R, Wilcock A. 2001 Symptom Management in Advanced
Cancer
• Travis S, Conway J. 2001 Terminal Restlessness in the Nursing
Facility, Geriatric Nursing 22(6): 308 - 312
Maintaining comfort in end of
life care
• Providing comfort focused care is central to
quality end of life care
• Maintaining comfort is the primary role of all staff
attending a resident in the last days of life.
Care context
• A number of comfort measures are considered
in end of life care.
These include:
– The need for a pressure relieving mattress
– The need for a single room (if an option)
Key comfort care areas are
Positioning
Mouth care
Eye care
Skin care
Micturition
Bowel care
Mouth care
• The care goal is that the mouth and lips be clean
and moist.
• Mouth care is reviewed regularly.
• Moist oral mucous membranes will tend to
prevent thirst.
• Local protocols for cleaning mouth and dentures
are used.
• Avoid alcohol based agents as these can
exacerbation “dryness”
Positioning
• The care goal is that a comfortable position be
maintained. Frequency of repositioning is
reviewed regularly.
• Comfort should take priority over pressure
relieving interventions that cause distress.
• Use individual’s“preferred” position as often as
reasonable.
• Use PRN analgesia in advance of repositioning
when indicated
Eye care
• The care goal is that eyes are clean and moist
• Eye toilets following local practice are used
• Eye lubrication is indicated if eye is dry
Skin care
• The care goal is that skin is clean and moist
• Avoid products that dry or harm skin
• The need for pressure area care should be
balanced against the need for comfort
• Wounds should be managed in the least
invasive way (no time to heal)
• If incontinent ensure skin protection products are
used
Micturition
• Care goal is that the individual be dry and
comfortable. Urinary aids such as pads should be
used if resident is incontinent
• Urinary output is reduced during the last days of
life
• Urinary retention should be excluded if individual
becomes restless
• Catheterisation is only used when it will improve
overall comfort
Bowel care
• The care goal is that the individual is not
agitated or distressed by constipation or
diarrhoea.
• Optimal bowel care prior to the last days of life,
especially in the presence of regular opioids,
contributes to overall comfort.
Bowel care
• Bowel products lessen in quantity as the end of
life approaches
• Once oral medications are not possible, in the
last days of life, other bowel management
agents are not usually used unless to reverse an
identified problem.
• A full rectum should be excluded if the individual
becomes restless (use suppositories).
Bibliography
• Glare P, Dickman A, Goodman M. 2003 Symptom Control in Care of
the Dying, in Care of the Dying: A pathway to excellence
• O’Connor M, Aranda S. (Eds) 2003 Palliative Care Nursing: A Guide
to Practice
• Wright K. 2002 Caring for the terminally ill: the district nurse's
perspective. British Journal of Nursing 11(18): 1180-5
Spiritual / religious / cultural issues in
end of life care
• Understandings, expectations and practices
relating to dying and death vary for each
individual
• Quality end of life care needs to address what, if
any, spiritual, religious or cultural factors are
important for each individual and their immediate
family during this time
• Identified needs are to be recorded and planned
for wherever possible
Spiritual / religious / cultural
care
• Relevant rituals / processes may apply
– Pre death
– At the time of death
– Post death
• Identifying these and facilitating their adherence
will support the individual and their family
Spiritual / religious / cultural
care
• Take an individual approach. Avoid
assumptions and stereotyping.
• If indicated, facilitate the practice of
identified rituals and provision of support.
• Utilise family contacts / resources.
• Negotiate the introduction of other pastoral
resources if indicated.
• Exercise cultural awareness and make
use of available resources.
Bibliography
• Hopper A. 2000 Spiritual care. Meeting the spiritual needs of
patients through holistic practice. European Journal of Palliative
Care 7(2): 60-2.
• Neuberger J. 2004 Caring for Dying People of Different Faiths (3rd
Ed)
• Speck, P. 2003 Spiritual / Religious Issues in Care of the Dying, in
Care of the Dying: A Pathway to Excellence
• Stanworth R. 2004 Recognising Spiritual Needs in People who are
Dying
• Woodruff R. 2004 Palliative Medicine (4th Ed)