Transcript End of life care education

End of Life Care Education
MODULE 1
Module 2
End of Life Care Symptom Management
Principles of End of Life Care Symptom Management
 Symptoms in the actively dying must be assessed at least once a
day.
 Symptoms must be anticipated and anticipatory prescription should
be written up
 Access and availability of essential medications for symptom control
should be ensured.
 Medications and doses prescribed for symptom control must be
based on careful evaluation of patient symptoms and problems
 Doses should be proportionate to patient’s symptoms and response
to treatment should be frequently reassessed
Principles of End of Life Care Symptom Management
 PRN (SOS) orders should be written up to cover intermittent
symptoms and to cover breakthrough events of persistent
symptoms
 Liberal use of PRN medications and rapid readjustment of
doses of background (round the clock) medication
 Route of drug delivery should be: most reliable, least invasive
and convenient
 Empower/Educate the family and caregivers to participate in
symptom management and care process
 Consider palliative sedation when symptoms are refractory to
adequate and aggressive palliative care
Six step EOLC Approach
Steps
Description
STEP 1
Identify
 “When to initiate”
 “Whom to initiate”
STEP 2
Assess
 Assessment of physical symptoms and distress
 Assessment of non physical issues
 Assessment of communication needs
STEP 3
Plan
 Site of care
 Review existing care protocol/medication chart and stop
all unnecessary interventions/medications/investigations
 Anticipatory prescription writing
 Communication, Consensus, Consent
Six step EOLC approach
Steps
STEP 4
Provide
Description
 Access to essential medication for EOLC symptom control
 Dedicated space and round the clock staff
 Special care needs of the patient and family
 After death care and bereavement support
STEP 5
Reassess
 Ensure adequate control of pain and other symptoms
through ongoing assessment
 Document any variance and initiate prompt action
STEP 6
Reflect
 Review the care process and identify if there were any
gaps
 Improving the EOLC process by constant reflection and
mindful practice.
EOLC Symptoms/Situations
1.
Pain
1. Psychological
2.
Restlessness/Agitation (Delirium)
2. Emotional
3.
Respiratory secretions
4.
Nausea & Vomiting
3. Social/Financial
4. Family
5.
Breathlessness
6.
Constipation
7.
Loss of appetite
8.
Fatigue
9.
Dry membranes
10.
Incontinence
5. Spiritual/Religious
6. Existential
EOLC Pain Management
 Pain is one of the most common symptom, difficult to assess and could
have varied presentations
 Should be anticipated and treated effectively
 Ensure access to controlled (strong) analgesics
 Use most reliable and convenient route of administration (SC or IV)
 Liberal use of PRN(SOS), rapid titration of background analgesics
Commonly used parenteral
analgesics in EOLC
 Morphine/Fentanyl (Nociceptive pain)
 Diclofenac/Ketorolac (Bone pain)
 Ketamine/Lignocaine (Neuropathic pain)
 Hyoscine/Octreotide (Colicky pain)
EOLC Pain Management
Noisy breathing
Tense body Language
Loud, harsh, labored breathing
Bursts of rapid breathing
Tense extremities ,tight fist, wringing
hands
Strained/Inflexible position
Negative Vocalization
Fidgeting
Noise or speech with disapproving quality
Hushed/low sounds constant muttering
Monotone with unpleasant sound
Moaning or groaning
Repetitive words with a mournful tone
Grunting or groaning
Restless, squirming, jittering
Guarding
Very irritable
Aggressive behavior
Sad facial expression
Hurt look, worried, troubled, distressed
Crying
Frightened facial expression
Scared looking, fearful
Alarmed appearance, pleading face
VARIED PRESENTATION
OF PAIN IN EOLC
EOLC Restlessness/Agitation(Delirium) Management
 Seen in up to 80-85% of patients at end of life
 Presents as acute onset, fluctuating disturbances in consciousness, sleepwake cycle disturbances, inattention, disorientation, hallucinations and
emotional disturbances
 Diagnosis is clinical
1.
(Confusion Assessment Method questionnaire)
2.
3.
4.
Implications of Delirium at End of Life
Acute onset &
fluctuating course
Inattention
Disorganized
thinking
Altered level of
consciousness
Impedes communication (families/ medical staff)
Affects symptom reporting, ability to make decisions or participate in decision making
Family distress, burden of decision making, misinterpret agitation as pain
Challenges professional care giving- difficult assessment/management
EOLC Restlessness/Agitation(Delirium) Management
 Non Pharmacological
Environmental management: Provide consistent, containing, and predictable
therapeutic space
Reorientation, reality testing, reassurance, explanation, anxiety reduction
Noise control, light intensity control, sleep-hygiene, improved staff-patient
communication, staff consistency and stimulus modification,
 Pharmacological
Typical anti-psychotic (Haloperidol) start smallest possible dose – slow
titration. Atypical anti-psychotics (Olanzapine, Risperidone, Quetiapine) in
selected patient groups/situations
Terminal delirium/Refractory delirium consider using Benzodiazepines like
Midazolam and Risperidone.
EOLC Respiratory Secretions Management
 Noises caused by upper airways secretions are heard in approximately 50%
of dying patients
 Caused by air passing through airways with secretions present (as the
patient is unable to swallow or clear them)
 The presence of respiratory secretions is a strong predictor of death (48% in
24 hours and 76% die within 48 hours from onset of this symptom)
 They are not usually distressing to patients in the terminal phase but, in
contrast, dominate the experience and memory of loved ones at the bedside
 Congestion Type I: Salivary Secretions accumulating when swallowing
reflexes are inhibited
 Congestion Type II: Bronchial secretions which cannot be coughed up or
swallowed
 Airway secretion can accumulate due to a. increased production, b.
decreased mucociliary clearance and c. ineffective cough reflex
EOLC Respiratory Secretions Management
Non pharmacological
Prevent aspiration with Repositioning
(Moving the patient from supine to lateral recumbent with head slightly
raised)
Encourages drainage, maintain airway and decrease pooling of secretions
Suction:
• Most secretions are usually below the larynx and inaccessible to
suction.
• Routine use of suctioning in the hospital setting needs to be
discouraged as it stimulates gag reflex which is extremly unpleasant
• Only indicated in presence of thick inspissated mucous, blood or other
fluid in the throat or mouth – suctioning may be of value
Good mouth care
Prevent over hydration
EOLC Respiratory Secretions Management
Pharmacological
Atropine 0.4 to 0.8 mg S.C. q4h and q1h p.r.n
Scopolamine (hyoscine hydro bromide) 0.3 to 0.6 mg S.C. q4 to 6h
regularly and/or p.r.n
Scopolamine transdermal patch 1.5 mg q72h; slow onset thus not
indicated in terminal phase unless augmented with subcutaneous
route for 8 to 12 hours.
Glycopyrrolate 0.1 to 0.2 mg S.C. q6 to 8h regularly and/or p.r.n.
does not cross the blood brain barrier thus should be considered in
non-obtunded patients.
EOLC Nausea and Vomiting Management
Approach
 Review current medications and discontinue any nonessential precipitating
drug
 Treat reversible causes e.g. Hypercalcemia
 Anticipate and prescribe a regular oral anti-emetic.
 If a patient is actively vomiting, consider parenteral route (intermittent or
CSCI)
Oral and parenteral drugs used for Nausea and Vomiting in EOLC
First line drugs
Adjuvant N+V drugs
Second line drugs
Metoclopramide
Haloperidol
Ondansetron
Dexamethasone
Lorazepam
Proton pump inhibitors
Cyclizine
Levomepromazine
EOLC Breathlessness Management
 Breathlessness is a common distressing symptom at end of life
 Breathlessness in EOLC is managed with four quadrant approach
EOLC Constipation Management
 Usually under recognized. Long standing constipation, fecal loading
could be very distressful
 Constipation in EOLC could manifest as abdominal pain, nausea and
vomiting, anorexia, delirium and distress
 Always consider laxatives as prophylactic co-prescription with strong
analgesics. Always combine stimulant laxatives with stool softeners.
 In patients unable to take orally, maintain regular bowel habit chart, and
always check for rectal impaction.
 Use rectal intervention measures like enema and manual evacuation
when necessary
 Always consider and rule out the possibility of bowel obstruction
EOLC Anorexia - Fatigue Management
 Fatigue is a common distressing problem in EOL and difficult to treat
Strategies to help fatigue management
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Activity enhancement / passive exercise if possible
Energy conservation and provision of aids and equipment
Nutritional assessment and correction of readily correctable
Psychosocial support
Pharmacological agents used in
Distraction and concentration techniques
Anorexia and Fatigue
Addressing sleeping related issues.
Steroids (Dexamethasone)
Pharmacotherapy has minimal role
 Anorexia is often associated with cachexia
Usually predicts poor prognosis
Megestrol Acetate
Methylphenidate
Modafinil
Eicosopentaenoic acid
L-carnitine
Cannabinoids
Potential reversible contributors should be sought and treated
Trial of pharmacological agents
EOLC Management of Dry Membranes and Skin
Positioning
Slightly on side, pillow support esp. trunk & shoulders
Head, minimally elevated
Change position every hours except in very last hours every 8-12 hours
Skin care
Good positioning prevents skin ulcers
Gentle cleansing – breakthrough analgesics if needed
Avoid elaborate dressings
Mouth care
Maintain good oral hygiene
Clean & moisten dentures; remove if drowsy
Hydrate with unflavored sponge tipped swab every 2-4 hours
Avoid commercial mouthwash, lemon glycerin, artificial saliva
Use 1L water/1/2 tsp. salt/1 tsp baking soda
Eye care
Methyl cellulose eye drops
EOLC Bowel and Bladder Care (Continence Care)
 Continence care is an essential medical/nursing aspect of care in EOLC
 Poorly managed bladder and bowels lead to urinary retention, urinary
incontinence, fecal impaction and delirium in elderly
 During EOLC – the final phase of dying the sphincters could relax and
lead to incontinence – alternatively retention can occur due to drugs
used for symptom control.
 Prompt recognition – Pads/Indwelling catheters may be required
 Proactive measures needs to be taken to prevent constipation/fecal
impaction in EOLC
 Rectal interventions are often required in patients with altered sensorium
and unable to take orally.
EOLC Special Issues
 Clinically assisted (artificial) hydration and (artificial) will not be of benefit
and decisions about their use should be individualized and made in
patient’s best interest
 Symptoms of thirst / dry mouth are often due to mouth breathing or
medication / oxygen therapy and good mouth care, frequent wetting of
mouth will alleviate symptoms of thirst.
 If clinically assisted artificial hydration or nutritional support is in place,
review rate/ volume / route according to individual need such that
complications related to overt hydration and parenteral nutrition at EOLC
is avoided.
 IV antibiotics at EOL should be rationalized and judiciously prescribed as
it may not confer any additional benefit during EOLC
EOLC Palliative Sedation
Palliative sedation is defined as medication-induced sedation that is
administered, without intending to cause death, utilizing a non opioid
drug to control intolerable symptoms that are refractory to conventional
treatment in patients with advanced and incurable disease whose death is
imminent (death expected in hours or days)
 Common conditions where Palliative Sedation is considered is
intractable pain, intractable dyspnea and intractable delirium
When to consider palliative sedation?
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Symptoms are refractory to pharmacological and non-pharmacological options
Death is imminent in days or weeks
Additional treatments are unlikely to bring relief
Aggressive palliative treatment has failed to control symptoms
Goal is relief of distress of symptom
Not enough time to try a potential non- sedative approach – impending death
EOLC Palliative Sedation
Steps involved in Palliative Sedation
All correctable corrected with maximal therapy
Aggressive palliative care interventions provided
Consensus among the treating physicians regarding imminent death
Communication with the family
Informed consent
Documentation of intent – Intent is always relief of symptom not otherwise
Provision of care
Management
First line
Haloperidol, Midazolam
Second line
Levomepromazine
Third line
Phenobarbital, Propofol
THANK YOU
This education program is a joint initiative of Indian Society of Critical Care
Medicine and Indian Association of Palliative Care. 2014
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