care of the imminently dying patient

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Presented to HPM Fellowship July 2010. Has handout also uploaded.

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  • 1. Care of the ImminentlyDying Patient July8 th , 2010 Christian Sinclair, MD Kansas City Hospice & Palliative Care

2. Prognostication of the Terminal Phase 3. Working with Ranges - Minutes 4. Working with Ranges - Hours 5. Working with Ranges - Days 6. Death Trajectories

  • Sudden Death
  • Death from Acute Illness
  • Death from Chronic Illness
  • After Withdrawal of Life Support

7. Scales

  • Palliative Performance Scale
  • Palliative Prognostic Index
  • Links available from:
    • prognosis.pallimed.org
    • EPERC Fast Facts

8. The Rally 9. What to Managevs. What to Expect Expect Manage 10. What to Managevs. What to Expect Expect Manage 11. Transforming from Patient-Centered Care to Family-Centered Care 12. Time and logistics Time & Logistics 13. Time and logistics Time & Logistics Physical Tasks 14. Time and logistics Time & Logistics Physical Tasks Financial Costs 15. Time and logistics Time & Logistics Physical Tasks Financial Costs Emotional Burden 16. Time and logistics Time & Logistics Physical Tasks Financial Costs Emotional Burden Physical Risks 17. Systems-Based Decline 18. Examination of the dying patient 19. Constitutional Weakness & Fatigue Fever & Hypothermia 20. Eyes & Oropharyngeal 21. 22. 23. Gastrointestinal

  • Anorexia Major family education point here GI shut down industrial analogy
  • Cachexia body image issues
  • Decreased Fluid Intake another major family education point
  • Incontinence - dignity

24. Cardiovascular

  • Hypotension
    • Hypovolemic
    • Cardiogenic
    • Septic
      • Poor cap refill, cyanosis, mottling, edema
  • Brady / Tachycardia
    • possible sign of distress body adjustment
  • Implantable Devices
    • think ahead about deactivation
  • Dont forget about blood pressure meds
  • Major prognostic value in imminent death
  • Can be fooled with variation

25. Renal 26. Pulmonary 27. Skin Care 28. Neurological/Psychological 29. Considerations of Location 30. 31. Spiritual/Existential Considerations 32. Medication Management

  • Prognosis / Goal Mismatch
    • If not aligned then change the medications
  • Pill Dysphagia
    • - Think ahead for other options
  • Alternate Routes
    • PR is not the only option
    • Topical medications eh.

33. Unexplained Prolongation of the Terminal Phase

  • No one has really looked at this population but it bears some examination.

34.

  • For a copy of the slides, please email: csinclair@kchospice.org
  • Recommended Reading/ Key References:
  • Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3 rdEd.
  • EPEC Last Hours of Living, Module 12, 1999.
  • Ferris FD, von Gunten CF, Emanuel LL.Competency in End-of-Life Care: Last Hours of Life.J of Pall Med.August 2003: 605-613.
  • Plonk WM, Arnold RM. Terminal Care: The Last Weeks of Life.J of Pall Med 8(5): 1042-55