HX2.1 Care of the Dying

Question 1

What are the leading causes of death?

Answer 1

1. Circulatory Disease
2. Cancer
3. Other
4. Resp
5. Injury and Poisoning

Question 2

What influences a persons fear/acceptance of death?

Answer 2

Culture/Society
Family
Religion

Question 3

What is a good death?

Answer 3

Paradoxical

Different for different people

Question 4

What are the element of quality in end of life care?

Answer 4

Care related to symptoms and personal care
–Pain and symptom control, being clean

Being prepared for death
–Having affairs in order, believing family is ready

Achieving a sense of completion
–Resolving unfinished business

Being treated as a whole person
–Maintaining dignity, not dying alone

Relating to family, society, care providers and the transcendent
–Coming to peace with God

Question 5

What is the central principle of end of life care?

Answer 5

Treat people, not pathology

Question 6

What are the elements that make up the whole person?

Answer 6

Physical
Psychological
Social
Spiritual

Question 7

Why is Dx of dying important? When does dying begin?

Answer 7

Needed for end of life care to begin.

Probably when we are diagnosed with incurable illness but important to focus on living after dx made i.e. Living up to the second you die.

Question 8

What are the consequences of failing to Dx dying?

Answer 8

• Negative consequences for pt, family, professionals
• Uncontrolled symptoms
• Inappropriate treatment plans – including CPR
• Conflicting messages
• Loss of trust, dissatisfaction, formal complaints
• Team disharmony

Question 9

Who diagnoses the dying?

Answer 9

Multi-disciplinary team decision

Question 10

What are the steps to be taken after a patient has been dx as dying?

Answer 10

• Document diagnosis
• Communicate diagnosis to patient
• Agree goal of care and ceiling of care with patient

Question 11

What principle governs the key decisions in promoting symptom management/quality of life? Give examples of some of these key decisions?

Answer 11

Benefit Vs Burden of interventions

Key Decisions
•Palliative chemotherapy
•Non-invasive ventilation
•Artificial nutrition
•IV antibiotics
•Do not resuscitate order
•Artificial hydration

Question 12

Describe the common symptom pathway to dying? Whom by?

Answer 12

• Pain
• Breathlessness
• Fatigue
• Terminal secretions
• Delirium

Solano 2005

Question 13

What are the indications for continuous subcutaneous infusion (CSCI)

Answer 13

• Patient too weak to swallow oral drugs
• Intractable nausea or vomiting
• Severe dysphagia
• Poor GI absorption

Question 14

What are the advantages of CSCI?

Answer 14

Advantages:
•Constant infusion (no peaks or
troughs)
•Reload once / 24 hrs
•Comfort and confidence (no repeated injections)
•Permits better control of nausea and vomiting

Question 15

What are the symptoms of a patient dying?

Answer 15

–Increased weakness and immobility
–Drowsy/cognitive impairment
–Reduced oral intake
–Difficulty taking meds
–Gaunt appearance
–Less able to converse

Question 16

What are the signs of a patient dying?

Answer 16

–Changes in breathing pattern
–Noisy/laboured breathing
–Changes in temperature regulation
–Circulatory changes: Cool peripheries/ pallor/ “marking”

Question 17

How should a doctor treat the moment of death?

Answer 17

• Private, family time
• Be there to reassure, but not as ‘chief mourner’
• Do not rush to confirm death
• Physical and emotional shock: all deaths are sudden
• Respect patient and family wishes re prayer, ritual etc.
• Slow, calm and serene

Question 18

What are the criteria required to confirm death?

Answer 18

• Unresponsive
• No respiratory effort
• No heart sounds auscultated x 2 mins
• Pupils fixed and dilated, not reaction to light

Question 19

What are the components of a patients preparation for death?

Answer 19

Practical
–Will
–Funeral arrangements
–Advance care plan

Deeper
–Memory box
–Some process of reminiscence

Older adults more likely to have made these arrangement

Question 20

What are the issues to consider when communicating with a patient and patients family about death?

Answer 20

Patient – How much to tell the pt?
–Balance hope and honesty

Family – Many questions
–Starving to death?
–How much time?
–Should we stay?
–Can he hear me?