Care in the last days of life

Dr Rosalie Shaw

The last days in life

Many younger healthcare workers have little personal or professional experience in caring for the dyingYet 58% of deaths occur in hospital in Singapore(Singapore Demographic Bulletin 2003, Registry of Births and Deaths, Singapore Immigration and Checkpoints Authority)

The last days in hospitalPatients often have troublesome symptomsResuscitation not consistently discussed (The Study to Understand Prognoses and Preferences for outcomes and Risks of Treatments (SUPPORT). JAMA 1995)

Even when death was expected, patients could be subjected to CPR (Seah, Low Chan. SMJ 2005; 46(%) : 210)

The last days of life

Diagnosing dyingWhat to doWhat to sayCommon ProblemsLiverpool Care PathwayDying at Home

Goals of care in the last days of life

Comfort and dignity essentialOther considerations –

Place of careSpiritual & emotional needsNeeds of loved ones

Is the patient dying?

Often preceded by steady deterioration over days to weeksVery weakDrowsyMay be disorientedHaving difficulty swallowingBreathing in abnormal patternSkin on feet and hands cool

Care of the Dying Patient

Discontinue all non-essential interventions – medication, monitoring, blood testsConvert essential medications to PR or subcutaneous routeAnticipate and plan for problemsPrepare the familyExplanation and reassuranceDiscuss and document DNR if not already done so

Medication in the Last Days

Stop all non-essential drugs e.g. anti-hypertensives, vitamins, laxativesContinue analgesics, anti-emetics, anti-psychotics, anxiolyticsPreferred route if unable to swallow –PR or subcutaneousAvoid IM (painful)Do not start Fentanyl patch (slow acting)

Problems to look out for

Noisy moist breathingPainBreathlessnessAgitation/ConfusionNausea/VomitingTwitching/Myoclonus

Reactions of family members

Care of the Family

Explain what is happening e.g. explain that when the breathing becomes irregular the patient is not “breathless”Get them involved – talk to the patient, simple tasks of caringThe comfort of touchAvoid burnout / exhaustionReligious and cultural considerations

Nutrition and Hydration

Decreased food and fluid intake are a natural part of the dying process.The patient is not “starving to death”Artificial nutrition (e.g. by NG tube) and hydration (e.g. by IV) do not significantly improve prognosis nor quality of lifeMay cause more distressPatient is not suffering because he/she is not eating/drinking.

Artificial Hydration (NGT or IV)

Can cause or exacerbate problems ofFluid retention e.g. ascites, oedemaSecretions e.g. vomiting, pulmonary congestion

No correlation with thirst or dry mouthGood mouth care essential for comfort

Noisy Terminal Breathing

“Death rattle” is more distressing for relatives than for patientPositioning and gentle suction of secretions from oral cavityDecrease secretions with sc hyoscinebutylbromide (Buscopan 20-40 mg prnup to 4 hourly) or hyoscine hydrobromide(Scopolamine 0.2-0.4mg)Can be given intermittently or as infusion

Terminal Restlessness/Delirium

Look for reversible factorsPainUrinary retentionFull rectumCerebral irritation/oedemaFear/anxietySide effects of medication

Terminal Restlessness/Delirium

Pharmacological management -Haloperidol (tranquilizer = calming) for agitation/deliriumE.g. subcutaneous 1 - 2.5mg stat, 2.5-5mg/24h

Midazolam (sedative = induce sleep) for anxietyE.g. subcutaneous 2.5mg stat, 5-10mg/24h

Liverpool Care Pathway

Translate best practice into template of care to guide healthcare professionals 3 sections:

• Initial assessment and care of the patient

• Ongoing care• Care of the family & carers after death

Ellershaw, Wilkinson (2003). Care of the Dying: A pathway to excellence. Oxford University Press

Liverpool Care Pathway

Promotes :Patient-centred careAwareness of needs of relativesConsistent practiceMultidisciplinary workingCommunicationDocumentation

Liverpool Care Pathway

The team must agree that the patient is in the dying phaseFor cancer patients:If condition has been deteriorating over the last few weeks/months and 2 out of the following:

Bed boundSemi-comatoseOnly able to take sips of fluidUnable to swallow tablets

Going home to die

“Terminal Discharge”

Going home for last hours/daysForewarned is forearmedIssues:

Supply of medication including sc infusion if indicatedIs oxygen required?Inform home care if availableInform Family Doctor if appropriateMemo or Discharge Summary to facilitate signing of Death Certificate (CCOD)

Dying at Home

Prepare family for the changes that occur close to, and at, the time of death

Heart stops, breathing stops, eyes may remain open, jaw may drop open

Give instructions about whom to callReassure them that they can return to hospital

After the Death

Doctor to certify death – no pulse + no breathing + pupils fixed and dilatedRemove catheter and any other tubesRemove pacemakerDoctor signs death certificate

After the Death

Sometimes team members also grieve after the death of a patient if:

younger patientunder your care for a long time

someone you identify withdeath is not expected

Team support is importantDebriefing after the death

Debriefing

Regular meetings to:Review outcomeConsider family needsConsider staff needs

Urgent meeting may be needed if very distressing death

Conclusion

What is appropriate for this patient at this time?What does the patient want?What does the family want or need?Support the family is as important as care of the patientStaff need each other’s support.

Death is not extinguishing the lamp. It is turning down the light

because the dawn has come

Tagore