Clinical Pearls:How to care for the dying patient

Suzana Makowski, MD MMM FACP

Overview

• Quick review of palliative care

• Recognizing hope at end-of-life

• How to assess patient

• How to manage symptoms

Family rating EOL care

Wanting Wanting

more pain more pain

reliefrelief

More More

physician physician

contactcontact

Wanting Wanting

more more

respectrespect

40-70% die in

pain

60%suffer

35% loose life savings

We don’t know what to offer

• Do you want us to do everything, or just…?

• If your heart stops, do you want us to use chest compressions to get it started again or to keep you comfortable?

• Your choice is either to have this PEG and maybe live for months, or to not have the PEG and go to hospice and die in a few days…

• You mean you don’t want us to intubate you? Not even a breathing machine (BiPAP)? Then what do you want us to do?

-Things I have heard

1-3 months prior to death

• Withdrawal from

outside world

• Withdrawal from

family

• Increased sleeping

• Gradual decreases

in eating

Hours to days prior to death

• Lower blood pressure

• Changes in heart rate

• Temperature fluctuations

• Increased perspiration

• Breathing fluctuations

• Skin color changes

• Further withdrawal,

perhaps confusion

• The relief of suffering, it

would appear, is considered

one of the primary ends of

medicine by patients and lay

persons, but not by the

medical profession.

-Eric Cassell

Skin

• Increased risk for wounds

• Requesting turns, appropriate bed

• Check skin integrity

• Barrier creams

• Wound care

• Moisturizer

Incontinence

• Loss of sphincter control

• Consider catheter – part of goals of care

discussion

• Meticulous skin care – requires increased nursing

checks, turns, etc.

• Puts patient at increased risk of skin breakdown

• Distressing to family

Pain

• Prevalence: 50%

moderate to severe

pain

• Evaluation of pain:

verbal patient, vs.

non-verbal

• Pain vs. delirium

• Treatment of pain:

• Opioids

• Non-opioid

analgesics

• Non-

pharmacologic

interventions

Breathing

• Assess difference between dyspnea

and normal changes in breathing

• Dyspnea: subjective, history

• Normal pattern changes: Δ tidal

volume, Cheyne-Stokes.

• Educate family and caregivers:

address myths

• “suffocating”

• Decrease in oxygen = suffering

Breathlessness

• Prevalence: as high as 70%

• Which diagnoses?

• Treatment options:

• Opioid: morphine, oxycodone, hydromorphone, fentanyl*

• Chlorpromazine (Thorazine)

• β-agonist

• Non-pharmacologic: fan, oxygen, stress-reduction (music,

etc.)

Nausea

• Zofran is NOT the be-all-and-end-all

• Know your pharmacology and pathophysiology!

Eyes – unable to close

• Cause: wasting of retro-orbital fat pad, causing orbit to

fall within orbital socket

• Treatment:

• Educate family and nursing

• Provide moisture to conjunctiva:

• Artificial tears

• Lacrilube

Secretions “death rattle”

• Associated with loss of ability to swallow and loss of gag.

• Gurgling, rattling

• Treatment:

• Educate family

• Medical intervention: Glycopyrrolate, hyoscine

hydrobromide (Scopolamine)

• Non-pharmacologic: Repositioning, postural drainage.

• Suction is not effective

Assuring good symptom control

• Medical management you have been prescribing still applies.

• Opioids may be helpful for dyspnea and pain

• Constipation is the opioid only side effect one does not gain

tolerance to give pro-motility (softener not enough)

• Respiratory suppression is due to overdose, not appropriate dose

• Terminal secretions: repositioning, stop artificial feeding and

hydration, anticholinergics – avoid suctioning why?

• Nausea: often due to dopamine receptor in chemoreceptor

trigger zone haloperidol = metoclopromide - promotility

• Delirium: common causes still apply and may be reversible! –

constipation, urinary retention, infection, pain, medications

Some pearls

Avoid morphine in renal failure – fentanyl, methadone, perhaps oxycodone preferable

Psychological Symptoms“Dying is not primarily a medical condition, but a personally experienced, lived

condition.” William Bartholme, MD. 1997. Kansas City.

Summary

• There is more we can do

• Assure non-abandonment

• Comfort care is not “just”

anything

• Sir William Osler:

• Eric Cassell:

“

“ “

“

Thank youThanks to many, including:

www.life.com (Sept 1, 2009),

my friends and family

How to learn more

• EPEC (Education on Palliative & End-of-Life Care)

• Lois Green Learning Community

www.loisgreenlearningcommunity.org

• Get Palliative: www.getpalliativecare.org

• Pallimed Connect