care of the imminently dying patient
DESCRIPTION
Presented to HPM Fellowship July 2010. Has handout also uploaded.TRANSCRIPT
Care of the Imminently Dying Patient
July 8th, 2010
Christian Sinclair, MDKansas City Hospice & Palliative Care
Prognostication of the Terminal Phase
Working with Ranges - Minutes
Working with Ranges - Hours
Working with Ranges - Days
Death Trajectories
• Sudden Death
• Death from Acute Illness
• Death from Chronic Illness
• After Withdrawal of Life Support
Scales
• Palliative Performance Scale
• Palliative Prognostic Index
• Links available from:– prognosis.pallimed.org– EPERC Fast Facts
The Rally
What to Manage vs. What to Expect
What to Manage vs. What to Expect
Transforming from Patient-Centered Care to
Family-Centered Care
Time and logistics
Time and logistics
Time and logistics
Time and logistics
Time and logistics
Systems-Based Decline
Examination of the dying patient
Constitutional
Eyes & Oropharyngeal
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
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
• Don’t forget about blood pressure meds
• Major prognostic value in imminent death
• Can be fooled with variation
Renal
Pulmonary
Skin Care
Neurological/Psychological
Considerations of Location
Spiritual/Existential Considerations
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.
Unexplained Prolongation of the
Terminal PhaseNo one has really looked at this
population but it bears some examination.
For a copy of the slides, please email: [email protected]
• Recommended Reading/ Key References:
• Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3rd Ed.
• 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