Terminal care Flashcards
what are the 13 points of terminal care?
- communication to patient and family
- place of care
- nursing needs
- food and fluids
- medication
- terminal restlessness
- death rattle
- distressing terminal events
- DNACPR
- documentation
- bereavement
- after death
what are the signs that someone is dying?
- Profound weakness
- Confined to bed for most of the day
- Drowsy for extended periods
- Disorientated
- Severely limited attention span
- Losing interest in food and drink
- Too weak to swallow medication
communication points about terminal care with the patient
- Sensitively check the patient’s understanding of what is happening and negotiate appropriate treatment.
- Encourage open communication and explore fears and concerns.
- The understanding of the family should be sought and their wishes considered (but not allowed to override those of the patient).
- Patients and carers will often have “unfinished business” (frequently legal, financial, interpersonal or spiritual issues). Be prepared to explore these and seek help if necessary.
- Remember spiritual and religious needs and offer to contact an appropriate faith leader such as a chaplain, priest, or Rabbi.
what to discuss about place of care in terminal care
The place of care and death should be negotiated – home, hospice, hospital, taking into account the needs and wishes of the patient and the family/carers.
nursing needs in terminal care
- Involve the family/carers in practical care as much as they wish.
- Treat dry mouth with good regular mouth care.
- Assess immobility and pressure areas - special beds or mattresses may be needed.
- Consider a catheter, convene, or pads for incontinence.
- Consider bowel care only if constipation is causing discomfort or agitation.
- Fast track/continuing care funding will enable patients to die at home or in a care home.
what is done about food and fluids in terminal care?
A reduced need for food and fluids is part of the normal dying process and patients should be supported to take food and fluids by mouth as long as tolerated.
Clinically assisted (artificial) hydration does not usually contribute to a dying patient’s comfort. It may worsen symptoms by increasing peripheral and pulmonary oedema. Possible benefits of withdrawing artificial hydration/nutrition include:
* Less vomiting and incontinence.
* Reduction in barriers between patient and family/carers.
* Prevention of painful venepuncture.
Remember patients are dying from their disease and not from lack of food or fluids. Dry mouth is usually related to medication, mouth breathing and/or oxygen therapy and is relieved by good mouth care.
rules around medications in terminal care and which medications should be stopped
Only continue medication needed for symptom management. If the oral route is not appropriate use the rectal, transdermal or subcutaneous route.
The following can usually be stopped when the patient is no longer able to swallow:
* Vitamins/iron
* Hormones
* Anticoagulants
* Corticosteroids
* Antibiotics
* Antidepressants
* Cardiovascular drugs
* Anticonvulsants used for pain
Patients should generally be prescribed an analgesic, antiemetic, anti-secretory and anxiolytic that can be given subcutaneously if needed.
how to assess and treat terminal restlessness
Look for evidence of any reversible causes such as pain, urinary retention, faecal impaction, respiratory secretions.
If no reversible cause can be found then sedation is often required. Midazolam is a useful short acting sedative/anxiolytic/muscle relaxant/anticonvulsant. It can be given subcutaneously either by stat doses (2.5mg-5mg sc) or infusion (starting at 10mg in 24hours). Sometimes levomepromazine may be needed.
causes of the “death rattle” (respiratory secretions) in end of life and treatment
This is a rattling noise produced by the movement of secretions in the upper airways, generally in patients who are too weak to expectorate effectively. Patients are generally not distressed by the noise but relatives and carers may find this distressing.
Repositioning of the patient may help. Otherwise antisecretory drugs such as hyoscine butylbromide (Buscopan®) or hyoscine hydrobromide (which may cause paradoxical agitation) may be needed.
which destressing terminal events can happen during end of life?
Events such as haemorrhage, fits, tracheal obstruction are unusual and can often be anticipated and a management plan agreed in advance.
DNACPR in end of life
If a patient is in the last days of life, cardiopulmonary resuscitation will not be of clinical benefit to them. The resuscitation status of the patient should be discussed within the clinical team and documented as per local policy.
documentation in terminal care
Most hospitals and increasingly primary care teams will use a personalized end of life care plan to guide and document care in the last days of life.
If at home/care home an Out of Hours Handover form should be completed.
Identify those at increased risk in bereavement such as people who:
- have had previous multiple losses or recent losses
- have ambivalent relationships
- have dependent children
- have lost a child
- have previous psychological problems or substance abuse
- live alone or feel unsupported
“after death” actions you may need to take
- Anticipate if a patient’s religion may necessitate special procedures after death. Ensure prompt provision of the death certificate and inform the patient’s GP within 24 hours.
- Warn relatives when referral to HM Coroner may be needed (e.g. mesothelioma).
- Provide information about the role of the funeral director, how to register a death, common feelings of grief, and support available.
- All doctors dealing with dying patients may need to seek support at some time. Professionals need to acknowledge and share feelings.
explain syringe drivers
Drugs commonly used in a syringe driver: their indications and warnings
