Transcript Is the resident agitated, restless or demonstrating

Preparing for the Predictable
Planning for common threats to comfort in
the final days.
Tamara Wells RN MN CNS
Dr. M. Harlos Medical Director
WRHA Palliative Care Program
Disclosures
• No conflicts of interest
• Many thanks to all the members of my team
and others for their insights and help with this
presentation.
Objectives
• To review some of the common predictable
symptom scenarios at end of life
• To review both pharmacologic and nonpharmacologic symptom management
strategies
• To discuss how end of life care is a team effort
Death in the PCH
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Residents live ~2.2 yrs post-admission
- 82% died in the PCH
- Diagnoses (Approx. 3 co-morbidities/death certificate)
Cardiovascular
67%
Dementia
41%
Infectious diseases
30%
Cerebrovascular
24%
Metabolic
17%
Cancer
10%
(K Klassen, S Wowchuk. WRHA chart audit, 2002)
Illness Trajectories
Sudden Death
Steady Decline/Expected Death
Steady Decline with Crises
Field & Cassel, 1997
Common Signs
• Functional decline
• transfers, toileting, eating
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Difficulty swallowing medications
Fatigue and decreased activity tolerance
Increased presentation of symptoms
Concerns of family and friends
Who is the team?
Family
Nurses/
Health Care Aides
Patient
Recreation/
Housekeeping
Allied Health Partners
Common Symptoms
1.
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6.
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Shortness of Breath
Confusion/Delirium
Pain
Loss of Appetite & Dehydration
Constipation
Nausea & Vomiting
Secretions
LTC End of Life Pathways
Dyspnea - Assessment
Resident describes air hunger/breathlessness
Or
Resident unable to describe dyspnea but exhibits
evidence of respiratory distress:
• Increased work of breathing
• Increased respiratory rate
• Using accessory muscles
• Agitated, restless, fearfulness
Non-Pharmacological
Management
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Position sitting upright
Cool air (fan or open window)
Oxygen for alert resident (& hypoxic)
Pace or minimize activity
Light bed covers, loose clothing
Good mouth care
Quiet music, calm presence, distraction
Pharmacological
Management
Medication
Indications
Route
Starting
Dose
Frequency
Morphine
Dyspnea (Pathway B)
Pain (Pathway D)
Oral/sublingual
2.5-5mg
q4h + q1h prn
Subcut
1.252.5mg
q4h + q1h prn
Dyspnea (Pathway B)
Pain (Pathway D)
Oral/sublingual
0.5-1mg
q4h + q1h prn
Subcut
0.250.5mg
q4h + q1h prn
hydroMorphone
(Dilaudid ®)
Delirium - Assessment
• Acute onset of global cognitive impairment
related to general medical condition with:
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Fluctuating consciousness
Disorientation
Disrupted sleep-wake cycle
Reduced attention
Perceptual disturbances
Disorganized thinking
Paranoid ideation
The Confusion Assessment Method
(CAM)
1. Acute onset
2. Inattention
3. Disorganized Thinking
4. Altered Level of Consciousness
5. Disorientation
6. Memory Impairment
7. Perceptual Disturbances
8. Psychomotor Agitation and Retardation
9. Sleep/Wake Cycle Disturbance
1 and 2
+
3 or 4
Delirium - Assessment
• If clinically appropriate & consistent with goals of
care- assess & treat potentially reversible causes
of delirium such as:
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Infections
Adverse medication effects
Metabolic abnormalities
Pain
Urinary retention
Hypoxia
Management
Is the resident agitated, restless or
demonstrating responsive behaviours?
NO
Hypoactive Delirium
• Sedation not indicated
• Provide general comfort measures
• Support family
Management
Is the resident agitated, restless or
demonstrating responsive behaviours?
YES=Hyperactive Delirium
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Non-pharmacological
Keep a calm and reassuring presence
Decrease environmental stimuli
Pace or modify activity
Monitor other factors that can impact comfort
(constipation, urinary retention)
Communicate with the team and family
Encourage sips of fluid
Pharmacological Management
Medication
Haloperidol (Haldol®)
Methotrimeprazine
(Nozinan®)
Indications
Agitated delirium –
Pathway A
Route
Starting Dose
Frequency
Oral or
sublingual
0.5-1 mg
q6-8h prn + q1h
prn
Subcut
0.5-1 mg
q6-8h prn + q1h
prn
5mg
q6-8h + q1h prn
5-25mg for
severe agitation
q6-8h + q1hprn
Agitated Delirium
Oral/subling
Pathway A
Nausea and Vomiting
/subcut
Pathway D
Delirium Monitoring
• Reassess every 24 hours or sooner depending
upon response
• Consider increasing dosages dependent upon
starting dose
• Consider stopping Haldol and moving to
methotrimeprazine if delirium non-responsive
to initial therapies
Noisy Secretions
Non-pharmacologic treatment
• Noisy secretions present AND distressing to
resident and/or family
• 1st: Try repositioning. “Best side”
• Oral suction? Only if visible oral or posterior
pharyngeal secretions
• No deep suctioning
Pharmacological Management
Is the Resident alert?
YES
• Glycopyrrolate 0.2-0.4mg
subcut q2h PRN
• If secretions persist:
consider using a scheduled
dose of glycopyrrolate 0.20.4mg subcut q6h & q1h
PRN
NO
• Scopolamine 0.3-0.6mg
subcut q1h PRN
• If secretions persist:
consider using a scheduled
dose of scopolamine 0.30.6mg subcut q4h & q1h
PRN
Pharmacological Management
Medication
Glycopyrrolate
Scopolamine
Indication
Noisy secretions Pathway C
Noisy secretions Pathway C
Route
Subcut
Subcut
Starting
Dose
Frequency
0.2-0.4 mg
q2hprn
If secretions
persist, q6h + q1h
prn
0.3-0.6 mg
q1hprn
If secretions
persist, q4h + q1h
prn
Noisy Secretions - Monitoring
• Review secretions management every shift
– Effective:
• Continue present treatment
• If receiving scheduled doses of glycopyrrolate or
scopolamine, consider switching to prn only
– Ineffective:
• Maximize doses and schedule of antisecretory
medications
• Reevaluate positioning of the Resident
• Support the family
Pain
• Pain may be related to medical complications
• Pain may be related to chronic conditions
• If pain exists it should be treated until end of
life
• Dying of itself is not painful
Pain Assessment
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Ask the patient (verbal indicators)
Observe the patient (non-verbal indicators)
Talk to family
Investigate the medical history
Present pain medications
Standardized reporting
PQRST
– Provoking factors, Quality of pain, Relieving factors,
Severity and Timing
Assessment Tools
Assessment Tools
Pain Assessment and Management
Patient already on Opioids
• If prn only consider
scheduled
• Change long-acting to short
acting equivalents
• Use q4h dosing for already
scheduled short acting
• Increase opioid factor by
20-100% dependent upon
context
• Monitor for best route
Patient not on Opioids
• Start with the lowest dose
• Start with the longest
interval
• Monitor regularly
• Use breakthrough opioid
when indicated
Pain-Pharmacologic Management
Medication
Indications
Route
Starting Dose
Frequency
Morphine
Dyspnea
(Pathway B)
Pain (Pathway
D)
Oral/sublingual
2.5-5mg
q4h + q1h prn
Subcut
1.25-2.5mg
q4h + q1h prn
Oral/sublingual
0.5-1mg
q4h + q1h prn
Subcut
0.25-0.5mg
q4h + q1h prn
hydroMorphone Dyspnea
(Pathway B)
(Dilaudid®)
Pain (Pathway
D)
Pain-Nonpharmacologic
Management
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Pace and prepare for activity
Use distraction and diversion
Communicate between team members
Decrease environmental stimuli
Provide for spiritual/psychosocial support
Reassure the patient/family
Manage hydration when able
Assessment
• Review every 24 hours
• Pain not controlled if >3/24 hours
• Pain controlled alert and less than <3
breakthrough doses/24hrs
• Monitor for over sedation
– If not using breakthrough but sedated consider dose
reduction of 20-50%
Sedation vs. Euthanasia
Dr. M. Harlos 03/12/14
When Death is Near
Declining energy and alertness
Decreasing intake of food and fluids
Difficulty swallowing
Mottling of the extremities
Changes in breathing pattern
Decreased urine output
Return to basic reflexes
When should you ask for help?
• Symptom control not being achieved
• Disagreement between team members
• Feeling uncertain about the steps you are
taking
• Goals of care have been unclear
• Help with conversion of medication
• other
Who can you call?
• WRHA Palliative Care Program
– 204-237-2400
– A Clinical Nurse Specialist or Physician will be able
to assist
Questions/Comments
Resources
1. Long Term Care Website:
http://home.wrha.mb.ca/prog/pch/EndofLifeCareEducationHandouts.php
2. Canadian Virtual Hospice: http://www.virtualhospice.ca
3. WRHA Palliative Program: 204-237-2400
4. Hospice and Palliative Care Manitoba for volunteer visiting and grief support
Phone: 204-889-5825