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 pain60%suffer35% 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:

“A good physician treats the disease; a great physician treats the patient who has the disease.

THE obligation of physicians to relieve human suffering stretches back into antiquity. Despite this fact, little attention is explicitly given to the problem of suffering in medical education, research, or practice. I will begin by focusing on a modern paradox: Even in the best settings and with the best physicians, it is not uncommon for suffering to occur not only during the course of a disease but also as a result of its treatment.

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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