Supportive care for dying in the final days Flashcards
(30 cards)
What is a good death?
- Freedom for pain
- At peace with God
- Presence of family
- Mentally aware
- Treatment choices followed
How does preparing the pt and family help at EOL?
- Reduces anxiety & fear
- Increases their confidence & competence to provide care
- Increases their sense of value & gifting
- Creates good memories of the experience
- Prepares them for impending losses
- Helps shift roles, responsibilities & support systems
- Reduces their dependence on HC providers (i.e., teaching how to give PRNs, maintain
lines in situ, etc.)
How can we promote a peaceful, dignified death?
- Maintaining the person’s basic sense of identity & self esteem
- Provide gentle, respectful care (body, mind & soul)
- Regard the individuals responsible & capable of clear perceptions, honest relationship &
purposeful behaviour despite physical decline (especially when a patient has decreased LOC)
How can we alleviate suffering during EOL?
-Controlling pain & other physical symptoms (we want them to participate in their
care and must be prepared with the EOL events like not being able to manage
ADLs independently, etc)
-Calming fears
-Helping the individual do the most they can, the best way they can
How can we provide privacy at EOL?
-Help preserve/restore the continuity of NB relationships
-Guide the individual/family to let go of former hopes & activities when appropriate
(need to help guide family in process of dying)
-Help fulfill a final wish or resolve a pressing concern
What are some things that should NOT be expected at EOL?
- Pain that can’t be controlled
- Breathing trouble that can’t be controlled
- “Going crazy” or “losing you mind”
What are some things that can be said to the patient/family about dying?
- If any of those problems come up, we will make sure that you are comfortable & calm,
even if it means that with the medications that we use you’ll be sleeping most of the time,
or possibly all of the time - You’ll find that your energy will be less, as you’ve likely noticed in the last while
- You’ll want to spend more of the day resting, and there will be a point where you’ll be
resting (sleeping) most or all of the day - Gradually your body systems will shut down, and at the end your heart will stop while
you are sleeping - No dramatic crisis of pain, breathing, agitation or confusion will occur (will not let this
happen; should be managed)
What should we do as the person is dying?
- Encourage family to talk to person even if she is not responding/seeming to hear
- Suggest they tell the dying person what she meant to them, how she will be remembered
& say their goodbyes - Use role modeling in words & actions
- Encourage gathering of family members & grieving
What are the non-physiological signs of approaching death?
-progressive dependence
-progressive withdrawal and detachment
What are the physiological signs of impending death?
- Decreased urine output, dark tea colored urine
- Weakening pulse
- Anxiety, restlessness, confusion, hallucinations AKA “delirium”
- Fluctuating LOC with gradual decline – accompanied by decreased awareness,
dysphagia (rattle/secretion initiates death rattle) & flaccid muscles - Changes in pattern & sounds of breathing – periods of apnea (Cheyne-Strokes), sound
of congestion - Progressive coldness, discoloration & mottling of skin (starts from the feet and goes )
- Dyspnea, congestion, agitated delirium are the most common signs of a person
dying
What are the predictable challenges in the final days?
- Functional decline – transfer, toileting
- Can’t swallow meds – alternative route of administration ie. subcut
- Terminal pneumonia (untreatable): dyspnea, congestion, delirium
- Concern of family & friends
- In cancer, common for the person’s temperature to
What should be implemented for a death at home?
- Expected death then prognosis is understood
- Patient and family are prepared
- Supports in place
- Service available (HCAs, nursing support, palliative nurse/physician on call)
- Contingency plan – alternatives (i.e., toileting: bathroom to bed pan, urinal, incontinent
pads, foley if needed, teach family how to use subcut lines as alternative, or teach family
how to use IN route, deprescribing, can also go back to the hospital)
What are the steps to do before they can go home and die at home?
- Have the end-of-life directive filled out by the patient
- Palliative drug program application sent and processed (so family avoids paying for
meds out of pocket) - Notification of anticipated death at home and direction from the patient’s physician
(5 copies):
1. Local or regional EMS
2. Funeral director (of chosen funeral home)
3. Office/chief of medical examiner or RCMP (if death occurs in a location where there
is no medical examiner
4. Keep one at home – some place that is easiest accessible (i.e., fridge)
5. Physician keeps one
What are the points to remember when pts enter the dying phase?
- Reconfirm a patient’s goals of care, preferred place of care, what to do in an emergency
- Connect with home nursing
- Ensure that required forms are completed (NO CPR/or Notification of Expected Home
Death) - Get discontinuation of non-essential medications
- Arrange subcut/transdermal medication, SL or IN administration when a pt is no longer
able to take medications via oral - Arrange for a hospital bed (+/- relief mattress)
- Arrange for foley catheter as needed
- Obtain an order for a SC anti-secretion medication (ie. atropine, glycopyrrolate)
- Standing order for home death
What are the anticipated symptoms during the dying phase?
Pain (most feared)
Dyspnea
Excessive respiratory secretions Agitation, confusion
Nausea & vomiting
Loss of appetite
Inability to swallow (aspiration risk) Dehydration
Incontinence (loss of bowel/bladder tone)
Note: days to even weeks before pt’s can be very fatigued and sleeping most of the time
to be expected
What does actively dying look like?
- Low level of consciousness – fluctuating LOC w/ gradual decline
- Changes in breathing patterns – rapid shallow breathing, Cheyne-strokes & moist
respirations (respiratory congestion) - Incotinence of urine or feces closer to impending death changes to dark concentrated
urine - Color & temperature changes: cyanosed nail beds, pallor (face), coolness of extremities –
mottling extremities
How can pain be managed at the end of life?
- Most common is use of SC meds, either continuation of previous opioid or initiation of low
dose of hydromorphone or morphine - Transdermal meds can be continued, but usually available in too high a dose to initiate at
this time - Sublingual & sub buccal & intranasal
What are the pharm interventions for dyspnea at EOL?
- Opioids: often low doses helps
- Hydromorphone 0.5 mg SC q4h regularly and 0.1mg q30min PRN
- Nozinan: starting dose 2.5-5 mg q8h and titrate effect - elderly pts respond better to
nozinan than benzos - Benzodiazepine: lorazepam 1-2mg q4h sl/sc, midazolam intermittently or csci 1-4mg/hr
for severe dyspnea & anxiety
What are the non-pharm interventions for dyspnea at EOL?
- Non-drug measures: fan, open window
- Home oxygen: if known to be hypoxic & oxygen has assisted in the past and if does not
increase restlessness; in imminently dying phase, do not monitor O2 sats & may remove
O2 as death approaches & dyspnea no longer a concern
What should be discussed with family regarding fluids and food in the terminal phase?
o Withdrawing from food & fluid is common aspect of dying process (anorexia)
o PEG tube does NOT contribute to better nutritional status or longer life, nor improves functional status or minimizes suffering
o Reduced food/fluid it NOT uncomfortable – dying pts who stop eating & drinking rarely experience discomfort d/t hunger
What is to be expected during the terminal phase regarding fluids and foods?
- Oral sips & good mouth care
- Need for hydration in other forms: hypodermoclysis or IV
- Discuss family’s understanding & expectations
What should the family be educated on regarding what to do after death?
- DO NOT call 911
- Call to notify the on-call palliative care nurse or physician
- Do you want the nurse or physician to come & pronounce the death?
- Call funeral home
- Forms for vital stats agency – within 48 hours of death (if death of <16 y.o., need to have form to RCMP/coroner’s office)
What can be done for dry mouth in the terminal phase?
- Provide mouth care w/ soft toothbrush and water
- Nonpetroleum gel to lips with turns or care (especially have oxygen on)
What can be done for excess respiratory secretions “death rattle” in the terminal phase?
- Can be distressing to family; prepare family for the changes before they occur
- Median time from onset to death is 8-23 hours
- Most common in patients with poor conditions, ¯LOC
- If alert – patient may be anxious and fearful of suffocating
- Terminology is important
