End of life Flashcards
(37 cards)
prognostication
process of predicting what a patients outcome is likely to be
- admission decisions
- treatment limitations - IPPV, RRT, extracorporeal life support
- tracheostomy
- invasive procedures
- withdrawal of life sustaining treatments
post cardiac arrest
OOH - < 10% survive to hospital discharge
in hospital - 25% survive to hospital discharge
Resus council - 72 hrsunconscious, GCS motor score 3 or less. 2 of
- absent pupillary light reflex
- Adverse CT/MRI (anoxic injury)
- Absent SSEPs
- Status myoclonus
- malignant EEG
- NSE > 60
Neurological outcome after brain injury
cerebral perfomance category
1 - good
2 - moderate disability independent
3 - severe disability (ambulant –> paralysis) conscious but dependent
4. coma or vegetative state (any impaired consciousness without brain death)
5. brain death
Modified rankin scale
0 - no symptoms
1 - symptoms but no disability - all ADLs
2 - mild disability - not all ADLs
3 - mod disability - help, walks without assistance
4 - mod severe disability - assistance to walk and bodily needs)
5 - severe disability - bed bound
6 - dead
frailty
Clinically recognisable state of vulnerability resulting from age related decline in reserve and function across multiple physiological systems such that ability to cope with everyday or acute stressors is compromised
performance status
initially used to assess patients independence in the context of malignancy
0 - fully active
1 - restricted strenuous activity
2 - ambulatory, self caring, unable to carry out work activities
3 - limited self care, confined to chair or bed 50%
4 - completely disabled confined to bed or chair
5 - dead
palliative care
holistic care of patients with advanced progressive incurable illness, to support patients to live well until they die
focus on symptom management and psychological, spiritual, social support
end of life
patients approaching end of life when it is likely they will die in the next 12 months
end stage is fine; period of progressive disease
futility
perceived non-benefit of treatment
- physiological - unable to maintain acceptable physiology
- quanititative - low chance of succeeding
-qualitative - cannot achieve acceptable QoLec
principles of EOL decision making
equalities
human rights
presumption in favour of preserving life
presumption of capacity
overall benefit
decision making for adults without capcaity
- be clear what decisions must be made
- check of legally binding advance decisions
- enquire whether someone holds legal authority to decide
- take responsibility for deciding which treatment will provide overall benefit, consulting’sg those close to patient
role of family
- provide information about patients wishes, preferences, feelings, beliefs and values
- don’t make decisions
- unless they have legal authority to make decisions on behalf of the patient who lacks capacity
disagreement about decisions surrounding EOLC
- seek advice from colleagues
- independent advocate
- case conference or ethics consultaion
- mediation services
- legal advice, independent court ruling
principles of withdrawing care
- not to prolong death, relieve symptoms and maintain dignity
- likely procedures involved e.g. extubation
- uncertainty about dying process, amount of time
- support
- how symptoms will be managed
withdrawing organ support
- individualised assessment
- stop non-comfort medications
- stop monitoring
- assess relevant symptoms
- sequential reduction in support - vasoactive medications, ventilatory support, extubation
special circumstances
- status epilepticus - continuing sedation
- NIV - weaning support and O2 to air
- MCS / ECMO - reduction in pump and gas flow
- ICD - deactivation
consequences of death for the individual
- cessation of resuscitation efforts
- religious ceremonies
- execution of will
- post mortem examination
- registration and certification of death
- organ donation
- disposition of body
somatic criteria for death
general recognition of death by another person (recognition of life extinct criteria)
- decapitation
- massive cranial disruption
- hemicorporectomy
- incineration
- decomposition / putrefaction
- rigor mortis
cardiorespiratory criteria for death
loss of consciousness
continuous apnoea and asystole
- cessation of circulation - absent pulse, absent heart sounds
- cessation of respiratory system - absent respiratory effort, no breath sounds
- cessation of cerebral function (5 mins after above) - fixed dilated pupils, no corneal reflex, no motor response to pain
time of death
at time of verification of life extinct
1st set of tests in brainstem death
37/ 40 - 2 months VLE
no heart sounds
no respiratory effort or breath sounds
no spontaneous movement or response to stimulation
medical examiner
provides scrutiny of all deaths
provide support for bereaved
improve quality of death certification and mortality data
coroner
independent judicial officer responsible for investigating a patients cause of death in certain circumstances
- who
- how, when, where death occurred
- may involve post mortem or inquest
clinical team responsible for referring appropriate cases
indictions for referral to coroner
- mechanism - unnatural trauma, self harm, neglect, poisoning, notifiable accidents/diseases, anaesthesia, post-operative
- unknown cause of death
- unknown patient
- patient in custody or state detention
coroner conclusions
- natural causes
- misadventure
- suicide
- unlawful killing
- lawful killing (self defence)
- industrial disease
- narrative - described circumstances but not bound by above
last offices
historical term used to describe care after death
- spiritual / cultural wishes
- preparing body for transfer to mortuary
- privacy, dignity
- honouring wishes for organ and tissue donation
if coronial involvement - leave all lines, keep infusions attached but clamped, do not wash or begin mouth care
no coronial - mouth care, tidy, clean, dress
Diagnosing death by neurological criteria
- Evidence of irreversible brain injury of known aetiology
- exclusion of reversible causes of coma and apnoea
- examination of absent brainstem function
