Issues among Death and Dying Flashcards
Barriers to the Diagnosis of Dying
- Unrealistic expectation that the patient may get better
- Disagreement within the team or with the family that the patient is dying
- No definitive diagnosis
- Lack of knowledge of the management of pain and other symptoms at the end of life
- Poor communication skills
- Concerns about withdrawing or withholding treatment
- Fear of foreshortening life
- Misinterpretation of the principle of double effect
- Concerns about resuscitation
- Cultural and spiritual barriers
- Legal complexities
Death trajectories
- Suddend death
- Steady progression
- Gradual decline punctuated by episodes of acute deterioration
- Prolonged gradual decline
Physiology of dying
Kubler-Ross theory
1. Denial and Isolation: Used by almost all patients in some form. It is a usually temporary shock response to bad news. Isolation arises from people, even family members, avoiding the dying person. People can slip back into this stage when there are new developments or the person feels they can no longer cope.
2. Anger: Different ways of expression
- Anger at God: “Why me?” Feeling that others are more deserving.
- Envy of others: Other people don’t seem to care, they are enjoying life while the dying person experiences pain. Others aren’t dying.
- Projected on environment: Anger towards doctors, nurses, and families.
3. Bargaining: A brief stage, hard to study because it is often between patient and God.
- If God didn’t respond to anger, maybe being “good” will work.
- Attempts to postpone: “If only I could live to see . . .”
4. Depression: Mourning for losses
- Reactive depression (past losses): loss of job, hobbies, mobility.
- Preparatory depression (losses yet to come): dependence on family,
etc.
5. Acceptance: This is not a “happy” stage, it is usually void of feelings. It takes a while to reach this stage and a person who fights until the end will not reach it. It consists of basically giving up and realizing that death is inevitable.
- Hope is an important aspect of all stages. A person’s hope can help them through difficult times.
Liverpool care pathway for the dying patient
Goal 1 Current medication assessed and nonessentials discontinued
Goal 2 PRN subcutaneous medication written up for the following indications as per protocol
Pain—Analgesia
Agitation—Sedative
Respiratory tract secretions—Anticholinergic
Nausea and vomiting—Antiemetic
Dyspnea—Anxiolytic/muscle relaxant
Goal 3 Discontinue inappropriate interventions
Goal 3a Decisions to discontinue inappropriate nursing interventions taken
Goal 3b Syringe driver set up within 4 hr of doctor’s orders
Goal 4 Ability to communicate in English assessed as adequate
Goal 5 Insight into condition assessed
Goal 6 Religious/spiritual needs assessed
Goal 7 Identify how family/other are to be informed of patient’s impending death
Goal 8 Family/other given hospital information via facilities leaflet
Goal 9 G.P. practice is aware of patient’s condition
Goal 10 Plan of care explained and discussed with
Patient
Family/other
Goal 11 Family/other express understanding of planned care
Pre-active Dying phrase (~2weeks)
- Restlessness
- Confusion, agitation
- Withdrawal from social interaction
- Increased sleep/lethargy
- Increased apnea
- Decreased intake
- Talking about he/she is dying
- Seeing died people
- Tying up “loose ends”
- Inability to heal wounds
- Swelling in extremities
Signs of the Active dying phase (~3days)
- Coma or Semi-coma
- Severe agitation, hallucinations, acting “crazy” and not in patient’s normal manner or personality
- Changes in the breathing pattern including apnea, Cheyne-Stokes but also including very rapid breathing or cyclic changes in the patterns of breathing (such as slow progressing to very fast and then slow again, or shallow progressing to very deep breathing while also changing rate of breathing to very fast and then slow), Agonal/ Ataxic
- Death rattle 57/82/23
- Inability to swallow any fluids at all (not taking any food by mouth voluntarily as well)
- Patient states that he or she is going to die
- respirations with mandibular movement (RMM) and no longer can speak even if awake 7.6/18/2.5
- Incontinence in a patient who was not incontinent before
- Reduced in urine output and darkening color of urine
- Blood pressure dropping (more than a 20 or 30 point drop)
- Cold extremities
- Numbness legs/feet
- Acrocyanosis, Mottling skin 5.1/11/1
- Rigid and stiffness
- jaw drop
Mean/SD/Median time to death by physical signs
- “Death rattle” Mean/Median:57/82//23
- Respirations with mandibular movement (RMM): 7.6/18/2.5
- Acrocyanosis/ moattling skin 5.1/11/1
- Radial pulselessness 2.6/4.2/1
Most common symptoms?
Most distressing symptoms?
- Fatigue, dyspnea, DRY MOUTH
- Fatigue, dyspnea, PAIN
Common Family Concerns
- Is my loved one in pain; how would we know?
- Aren’t we just starving my loved one to death?
- What should we expect; how will we know that time is short?
- Should I/we stay by the bedside?
- Can my loved one hear what we are saying?
- What do we do after death?
Death rattle
- Patient loss ability to clear secretion
- 2 types: Salivary and Bronchial
- Median time to death = 16hrs
- REassure family: the noisy respiratory secretions are unlikely to be distressing for the patient who is unconscious
Management
- Reposition
- Gentle oropharyngeal suction
- STOP IV
Medical
Only work for upper secretion; Not for lower airway, pul edema and pneumonia.
- Glycopyrolate: quternaly amine less CNS side-effect
- Scopolamine: dried mouth, confuse
- 1% opth sol Atropine 1gtt SL
“But she’s starving to death…”
- 25% of patients with advance dementia die with feeding tube
- This is emotional issues
- OK for therapeutic trial feeding event artificially: MAKE sure to CLARIFY GOAL and TIME.
ADDRESS feeding tube
“Though the feeding tube will address the nutrition and hydration concerns; however, it’s uncomfort, put the patient at risk for complications and will not prevent patient’s from aspiration.”
- All dying patients lose their interest in eating in the days to weeks leading up to death, this is the body’s signal that death is coming.
- I am recommending that the (tube feedings, hydration, etc.) be discontinued (or not started) as these will not improve his/her living; these treatments, if used, may only prolong his/her dying.
- Your (relation) will not suffer; we will do everything necessary to ensure comfort.
- Your (relation) is dying from (disease); he/she is not dying from dehydration
or starvation.
When artificial nutrition and hydration should be offer?
- Amyotrophic lateral sclerosis
- HIV
- Patient recieving XRT/Chemo in proximal GI tract
- Patient with good FUNCTIONAL STATUS having upper GI obstruction due to cancer
- Head and neck cancer
- Short bowel syndrome
- Patients with reversible illness in a catabolic state
- ACUTE phase of a stroke or head injury
- SHORT-term ICU
Address of hydration/ thrist/ DRY mouth
“Supplemental fluid s do not treat the sensation of thirst. In fact, the sensation of thirst can be well treated with oral swabs, ice chips and moisturizers.”
