Dr Yassir NourEldaimConsultant of Anaesthesia&ICU

“Caring for a Dying Patient”

‘Am I Going To Die?’

Introduction•Every year, more than half a million people die in the United Kingdom, and over half of these deaths occur in hospital.• Junior doctors are often required to care for dying patients•Early recognition of dying facilitates meeting patients’ and relatives’ preferences for end of life care•Communication is the cornerstone of good end of life care•The principles of end of life prescribing are: to stop non-essential drugs; convert essential drugs to the subcutaneous route; and use anticipatory prescribing

Cont: Introduction

•Terminal care is not just cancer care but other relevant diseases include:

1. Heart failure.2. Respiratory failure.3. Chronic renal failure.4. Hepatic failure.5. Certain neurological diseases such

as multiple sclerosis and motor neurone disease,.

6. AIDS.

keys•The key to managing and supporting the dying patient involves:

1. Identifying that the patient is dying.

2. Continuous assessment of symptoms & psychological/spiritual needs.

3. Anticipating likely problems before they arise so that treatments are readily available.

4. Appropriate & prompt management of symptoms

Strategic goals for the dying patient

Both the patient’s/family’s awareness & understanding of diagnosis of dying is communicated and documented.

Patient is assessed and a care plan is developed in line with the patient’s/family’s wishes.

Clinical goals for the dying patient

1. Current medication assessed & non-essential medicines discontinued.

2. PRN subcut meds/fluids written up as appropriate.

3. Inappropriate interventions discontinued e.g. blood tests, BP monitoring.

4. Cardiac defibrillators (ICDs) deactivated in consultation with cardiologist.

5. DNAR order completed.6. Organ donation considered

Ongoing assessment goals for the dying patient

1. Patient is free from pain, agitation, excessive respiratory tract secretions & nausea/vomiting,severe breathlessness.

2. Pressure care - if death is imminent, reposition for comfort only – consider pressure relieving mattress.

3. Bowel care – patient is free from bowel problems causing distress.

4. Urinary status – patient has appropriate aids.

5. Eyes, mouth & lips clean & moist - consider family involvement in these tasks, if appropriate

Cont:Ongoing assessment goals for the dying patient

1. Emotional & psychological care– patient and family have appropriate support

2. Spiritual, religious and cultural support – needs are assessed and supported

3. GP and community team informed of the patient’s condition

4. Goals to support the family as the patient nears death

5. Next-of-kin / significant others identified & contact details recorded.

6. Family prepared as far as possible for the patient’s death

5 physical symptoms associated with dying

Regular / PRN subcutaneous medications

1. Pain. 1. Analgesics (e.g.morphine)

2. Agitation & distress.

2. Sedatives (e.g. midazolam)

3. Respiratory tract secretions (‘noisy rattle’).

3. Anti-cholinergics (e.g. hyoscine hydrobromide)

4. Nausea & vomiting

4. Anti-emetics (e.g. metoclopramide )

5. Breathlessness

Pronouncing Death

•It is important to pronounce andconfirm death in a professional yetcompassionate manner, knowing thatthe family will remember acutely thistime, your words, and the tone of yourvoice.

Death Certification•A death certificate is available from the local registrar of Births Deaths and Marriages by providing the following details to register the death:

1. Full name and surname of the deceased2. Gender, marital status, occupation and date

of birth or age of the deceased.3. Date and place of death.4. If deceased was married, the occupation of

their spouse, or deceased spouse if widowed.5. If deceased was a child, the occupation of the

father or, if the parents were not married the occupation of the mother.

6. Death Notification Form of the Cause of Death.