18.3 (18.1) Management of the actively dying patient

Question 1

What is the terminal phase of illness? What time frame does it usually describe?

Answer 1

the period of irreversible decline in functional status and well-being prior to death
(a distinct period in which death can no longer be deferred)

few hours - days - occasionally weeks

Question 2

How might the patient/family experience intensify in the termianl phase?

Answer 2

Increasing prevalence and intensity of physical, psychological, existential, and social concerns

Question 3

List 7 symptoms that indicate the terminal phase of life has been reached

Answer 3

Table 18.3.1```
profound/persistent weight loss
profound weakness and fatigue
social withdrawal
disinterest in food and drink
dysphagia and difficultly swallowing meds
refractory delirium
drowsy for extended periods
~~~

Question 4

List 6 physical signs that suggest proximity to end of life

Answer 4

TABLE 18.3.1:

1. Changes in breathing: persistent tachypnea, irregular breathing, periods of bradypnea
2. Changes in skin with peripheral vascular shut down, skin that is cool to touch
3. Deepening jaundice
4. Reduced urine output
5. Hypotension
6. Progressive hypoxemia

Question 5

List four outcomes of well conducted discussions about end of life care for patients and families

Answer 5

• reduced number of aggressive medical interventions near death
• reduced distress
• improved QOL for both patient and family/caregivers
• reduction in family/caregiver bereavement morbidity when dying patient had benefit of EOL discussion
• foster trust and non-abandonment between physician and patient

Question 6

John does not want you to tell his father Jack that Jack is approaching the terminal phase of his illness as he suspects it will cause emotional or psychiatric distress for Jack. What do you tell John?

Answer 6

Studies have shown these conversations are not associated with emotional or psychiatric distress for patients

Above answer is from 5th edition. In 6th edition, more recent studies suggest patients with high prognostic awareness had greater anxiety/depression - so, it’s controversial…

Question 7

List four critical needs of the family during the terminal phase of a patient’s illness

Answer 7

Table 18.3.1:
- patient comfort

• information and communication
• care education
• preparing the family for dying process
• evaluation of family needs and resources
• emergency provisions
• review of family coping
• care of family when patient unconscious

Question 8

Dr. Smith does not want to have a conversation with John about CPR and DNR because he has known John for 30 years and is worried that this conversation will damage their longstanding relationship. What do you tell Dr. Smith when he consults you to have the conversation in his place? What do you tell Dr. Smith is very important to focus on in the conversation other than the code status?

Answer 8

These conversations have not been found to change patient or surrogate satisfaction with the clinician

The conversation should focus on what can and will be done for the patient at EOL with an emphasis on dignity, comfort, and prevention of distress

Question 9

List two significant benefits of advanced care planning for people at risk of losing decision making ability

Answer 9

reduces burden on the SDM

ensures that patient’s wishes are respected

Question 10

List 2 pieces of practical advice you would give to a family caring for a patient approaching end of life, regarding:

1. Decreased socialization
2. Decreased eating
3. Disorientation/confusion
4. Incontinence
5. Congestion
6. Fever
7. Coolness

Answer 10

Table 18.3.2:

1. Decreased socialization:
   - plan activities/visits when most alert
   - identify yourself/what you are going to do
   - don’t say anything you wouldn’t if awake
2. Decreased eating:
   - let pt be guide if they want food/fluids
   - liquids preferred to solids
   - frequent mouth care for comfort
3. Disorientation/confusion:
   - Gently reorient pt to yourself/place
   - Reassure of your presence/care/safety
   - Do not argue/contradict their experience
4. Incontinence:
   - adult disposable briefs/underpads
   - catheter to keep skin dry
   - barrier creams
   - ensure privacy with personal care
5. Congestion:
   - gently turn to side (gravity may help drain secretions)
   - raise head of bed
   - opioid for laboured breathing or meds for excess secretions
6. Fever:
   - cool cloth to the forehead
   - fan/opening window
7. Coolness:
   - warm blanket
   - gentle massage

Question 11

1. List 4 common psychosocial/existential issues at end of life
2. List 4 ways patients might want to attend to these issues
3. List one way HCP play an important role in a patients ability to address these issues

Answer 11

1. • fear of death
   • issues related to loved ones/family
   • guilt
   • remorse
   • need for forgiveness or need to forgive
   • issues around meaning
2. Patients will want to attend to issues of:
   - separation, farewell, legacy by leaving a final message to loved ones
   - confession
   - prayer
   - finding spiritual solace
3. • Prognostication - above tasks can go unattended if patient/family aren’t aware death could be close
   • spiritual care referral - helps reduce distress, enhance coping

Question 12

List 6 causes of relatively refractory dyspnea at end of life.

Answer 12

1. Obstructing tumour
2. frailty and weakness
3. restrictive respiratory conditions, including chest wall disease
4. lcoulated pleural effusions not amenable to drainage
5. lymphangitic carcinomatosis
6. diffuse extensive lung pathology
7. pleural infiltrates
8. overwhelming infection

Question 13

A patient has an agitated delirium and cannot swallow. List four antipsychotics that can be given and their routes of administration

Answer 13

Table 18.1.2
Methotrimeprazine - sc
haldol - sc/iv
loxapine - sc
olanzapine - PO (instant dissolve wafer)
chlorpromazine - rectal

Question 14

A patient is on subcut opioids and PO amitriptyline for neuropathic pain. They are no longer able to swallow. There is no evidence of pain. What will you do with the amitriptyline and opioid?

Answer 14

Continue the opioid

Discontinue amitriptyline and consider PRN ketamine if pain worsens?

Question 15

List three mechanisms to explain Type 1 death rattle

Answer 15

Type 1 death rattle is

(1) pooling of saliva and secretions in upper airway

(2) reduced swallowing reflexes /dysphagia

(3) inability to expectorate

Question 16

List 4 aetiologies for type II death rattle

Why is it important to distinguish this from type I death rattle.

Answer 16

Type 2 death rattle is due to pooling of bronchial secretions

bronchorhea from primary lung tumor*
infection*
aspiration pneumonitis
bronchial or alveolar bleeding
dysphagia 
airway obstruction
pulmonary edema*
tracheoesophageal fistula

2. Type II may not respond as well to antimuscarinic/anticholinergic meds

SS: I’m not sure why some answers have asterisks from 5th edition

Question 17

What defines a refractory symptom in palliative care?

Answer 17

suffering is considered refractory if despite use of aggressive and concerted efforts to determine and treat the cause, suffering persists

6th edition definition:
refractory: symptoms that cannot be adequately controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness”

This term is used when further interventions are:
1) Incapable of providing adequate relief
2) associated with excess/intolerable acute/chronic morbidity
3) unlikely to provide relief within tolerable time frame

Question 18

A family is distressed that their loved one in the terminal phase is not able to drink and is dehydrated. They are asking for IV fluids.

a. List two points you would discuss with them
b. The patient is already on IV fluids and family wants to continue for cultural/religious reasons. What do you tell them?

Answer 18

a. 1. ineffectiveness and burden of artificial hydration vs any likely benefit
2. Maintaining good mouth hygiene alleviates much of the sensation of thirst and discomfort
b. It may be maintained unless there is evidence of patient harm from the intervention. Warn that edema or discomfort would be reason to d/c

Question 19

Only essential medications/interventions contributing to a patient’s comfort should be continued at end of life.

How would you approach each of the following scenarios?

1. The patient/family have persistent reservations about withdrawal of a medication (e.g. antibiotic) that is NOT causing the patient any harm.
2. There IS concern for harm with the therapy

Answer 19

1. The patient/family’s opinions should generally prevail and medication should be continued
2. Propose a time-limited therapy with re-evaluation of its merit

Question 20

Before initiating sedation for agitated delirium what other diagnoses should you exclude

Answer 20

status epilepticus
akathisia
seritonin syndrome
myoclonus
physical pain or discomfort in obtunded patient (ie. from itch, physical pain, fecal impaction)
medication side effects
hypoxia

Question 21

1. What is the association between hydration status and development of death rattle?
2. Which type of death rattle is a strong predictor of approaching death?

Answer 21

1. NO association
2. True (type 1) - in one study, 76% of patients died within 48 hrs of its onset

Question 22

List 5 important steps when delivering sedation for refractory symptoms

Answer 22

1. Evaluation and consultation (exclude reversible causes, consider specialist input)
2. Consent requirements (from pt or SDM)
3. Administration of sedation (mild vs deep, intermittent vs continuous)
4. Patient monitoring (comfort vs monitoring vitals if not at EOL and goals for less sedation)
5. Care of the sedated patient’s family

Question 23

List 3 reasons sedation for refractory existential or pyschological distress may be more controversial (than for other symptoms)

Answer 23

1. Much more difficult to establish that these symptoms are refractory (sx fluctuate, psychological adaptation/coping is not uncommon)
2. The standard treatment approaches are not burdensome + don’t have problematic side effects
3. These symptoms may occur even when death is not imminent

Question 24

Beyond the usual considerations, list 3 important considerations when addressing sedation for refractory existential distress

Answer 24

1. “refractoriness” should only be designated after period of repeat assessments by clinicians skilled in psychological care who establish relationship with patient/family. This is along with routine approaches to anxiety/depression/existential distress
2. Evaluation should be made in multidsicplinary approach (psych, spiritual care, ethics, medical team)
3. Infrequently, when sedation is appropriate, should trial respite sedation first and reassess.

Consider continuous only after repeat trials of respite sedation with intensive intermittent therapy

Question 25

List 3 important considersations to support family at or after the death of the patient.

Answer 25

1. When agonal breaths, reassure family re: patient’s comfort and not in distress
2. Awareness and respect for cultural and/or religious practices
3. Offer of condolensces
4. Adequate provision for family privacy and time with the body
5. Bereavement support