the final day(s) keeping the promise of comfort
TRANSCRIPT
THE FINAL DAY(S)THE FINAL DAY(S)
Keeping the Promise Keeping the Promise
of Comfortof Comfort
Post-99Ischemic
Encephalopathy
Discontinued Dialysis
Cancer
Stroke
Neuro-Degenerative
End-StageLung Disease
• Bedridden• Can’t clear secretions
Pneumonia
Dyspnea, Congestion,Agitated Delirium
Main Features of Approach to CareMain Features of Approach to Care
• Perceptive and vigilant regarding changes
• “Proactive” communication with patient and family» anticipate questions and concerns» available» don’t present “non-choices” as choices
• Aggressive pursuit of comfort
• Don’t be caught off-guard by predictable problems
• Functional decline- transfers, toileting
• Can’t swallow meds- route of administration
• Terminal pneumonia» dyspnea» congestion» agitated delirium
• Concerns of family and friends
Patient Care Challenges in the Final DaysPatient Care Challenges in the Final Days
Concerns of Patients, Family, and FriendsConcerns of Patients, Family, and Friends
• How could this be happening so fast?
• What about food & fluids?
• Things were fine until that medicine was started!
• Isn’t the medicine speeding this up?
• Too drowsy!
• Too restless!
• We’ve missed the chance to say goodbye
• What will it be like? How will we know?
difficult transfers
bedridden
completely dependent
increasingly drowsy
comatose
Functional DeclineFunctional Decline
Steady decline Accelerated deterioration begins,medications changed
Rapid decline due to illness progression with diminished reserves.
Medications questionedor blamed
Which Came First....The Med Changes or the Decline?
Day 1Day 1 FinalFinalDay 3Day 3Day 2Day 2
The Perception of the “Sudden Change”
Melting ice = diminishing reserves
When reserves are depleted, the change seems sudden and unforeseen.However, the changes had been happening.
Family / Friends Wanting to InterveneFamily / Friends Wanting to InterveneWith Food and / or FluidsWith Food and / or Fluids
• distinguish between prolonging living and prolonging dyingdistinguish between prolonging living and prolonging dying• parenteral fluids not needed for comfortparenteral fluids not needed for comfort• pushing calories in terminal phase does not improvepushing calories in terminal phase does not improve function or outcomefunction or outcome• “ “We can’t just let him die”We can’t just let him die” ““Not letting him die” implies that you can “make him Not letting him die” implies that you can “make him
live”, which is not the case. The living vs. dying live”, which is not the case. The living vs. dying outcome is dictated by the disease, not by what you or outcome is dictated by the disease, not by what you or the family decides to do.the family decides to do.
Patient’s LifetimePatient’s Lifetime
Time that death would have occurred without intervention
Extending the final days in terminal illness:Prolonging life or prolonging the dying phase?
Consider the rationale of trying to prolong life by adding time to the period of dying
OBTAINING SUBSTITUTED JUDGMENTOBTAINING SUBSTITUTED JUDGMENT
You are seeking their thoughts on You are seeking their thoughts on
what the patient would want, not what what the patient would want, not what
they feel is “the right thing to do”.they feel is “the right thing to do”.
““If he could come to the bedside as healthy as If he could come to the bedside as healthy as he was a year ago, and look at the situation for he was a year ago, and look at the situation for himself now, what would he tell us to do?”himself now, what would he tell us to do?”
OrOr
““If you had in your pocket a note from him telling If you had in your pocket a note from him telling you that to do under these circumstances, what you that to do under these circumstances, what would it say?”would it say?”
PHRASING REQUEST: SUBSTITUTED JUDGMENTPHRASING REQUEST: SUBSTITUTED JUDGMENT
Usual response is for comfort Usual response is for comfort
care only; emphasize then that care only; emphasize then that
we have no right to do otherwise.we have no right to do otherwise.
“Many people think about what they might experience as things change, and they become closer to dying.
Have you thought about this regarding yourself?
Do you want me to talk about what changes are likely to happen?”
TALKING ABOUT DYING
First, let’s talk about what you should not expect.
You should not expect:– pain that can’t be controlled.– breathing troubles that can’t be controlled.– “going crazy” or “losing your mind”
If any of those problems come up, I will make sure that you’re comfortable and calm, even if it means that with the medications that we use you’ll be sleeping most of the time, or possibly all of the time.
Do you understand that?Is that approach OK with you?
You’ll find that your energy will be less, as you’ve likely noticed in the last while.
You’ll want to spend more of the day resting, and there will be a point where you’ll be resting (sleeping) most or all of the day.
Gradually your body systems will shut down, and at the end your heart will stop while you are sleeping.
No dramatic crisis of pain, breathing, agitation, or confusion will occur -
we won’t let that happen.
Basic Medications in The Final Day(s)Basic Medications in The Final Day(s)
SYMPTOM MEDICATION
Pain Opioid
Dyspnea Opioid
Secretions Scopolamine
Restlessness Haloperidol + Midazolam or Lorazepam Methotrimeprazine
National Hospice StudyNational Hospice StudyDyspnea DataDyspnea Data
• n = 1764 n = 1764
• prospectiveprospective
• Dyspnea incidence: Dyspnea incidence: 70 %70 % during last 6 wks. of life during last 6 wks. of life
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest 1986;89(2):234-6.Chest 1986;89(2):234-6.
25
35
45
55
65
75
42 21 7
# Days Prior to DeathPre
vale
nce
of
Dys
pn
ea (
%)
National Hospice StudyNational Hospice Study Dyspnea PrevalenceDyspnea Prevalence
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest 1986;89(2):234-6.
Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P. Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P. Dying from cancer: the views of bereaved family and friends about the experience Dying from cancer: the views of bereaved family and friends about the experience of terminally ill patients.of terminally ill patients. Palliative Medicine 1991 5:207-214Palliative Medicine 1991 5:207-214..
• n = 80 Last week of lifen = 80 Last week of life• severe / very severe dyspnea: 50%severe / very severe dyspnea: 50%
less than ½ of these were offered effective treatment
HOW WELL ARE WE TREATING DYSPNEA IN THE TERMINALLY ILL?
1. Opioid - pain, dyspnea
2. Antisecretory - congestion
3. Sedative - restlessness, confusion
Basic Medications in The Final Day(s)Basic Medications in The Final Day(s)
Examples of Opioid Prescription / OrdersIn Absence of a Protocol
Examples of Opioid Prescription / OrdersIn Absence of a Protocol
Example 1Morphine 5 - 20 mg po/SL/pr q4h.- Start with 5 mg dose. Titrate or by 5 mg .- Breakthrough = the current q4h dose given q1h prn.
Example 2Hydromorphone 0.5 - 2 mg/hr IV/SQ sage.
- Start with 0.5 mg/hr. Titrate or by 0.1- 0.2 mg/hr
- Breakthrough = the current hourly dose q30 min prn.
Sedation in Delirium if No SQ Route Available or if Not Necessary
Sedation in Delirium if No SQ Route Available or if Not Necessary
Moderate: methotrimeprazine 12.5 - 25 mg po/SL OR haloperidol 2.5 - 5 mg po/SL
+ / - lorazepam 1 - 2 mg SL
(Also consider chlorpromazine supps 50 - 100 mg pr q4h)
q4h plus q1h prn
Mild: haloperidol 0.5 – 2 mg po or (injectable) SL bid + q6h prnOR risperidone 0.5 – 1 mg po bid plus q6h prnOR methotrimeprazine (elixir or injectable) 6.25 – 12.5 mg po/SL q6-8h + q4h prn [NB:Taché Pharm. makes 40mg/ml elixir)
q4h plus q1h prn
Severe: methotrimeprazine 25 - 50 mg po/SL OR haloperidol 5 mg po/SL AND lorazepam 2 mg SL
Sedation via SQ Route in DeliriumSedation via SQ Route in Delirium
Moderate: haloperidol 2.5 - 5 mg OR methotrimeprazine 25-50mg +
midazolam 2.5 - 5 mg
SQ q4h plus q1h prn
OR: SQ infusion of:
methotrimeprazine 6.25 - 12.5 mg/hr + midazolam 1.25 - 5 mg/hr
SQ q4h plus q1h prn
Severe: haloperidol 5 mg OR methotrimeprazine 50mg +
midazolam 10 – 20 mg
Mild: haloperidol 0.5 - 2 mg SQ bid ORmethotrimeprazine 6.25 – 12.5 mg SQ 6 - 12h
CONGESTION IN THE FINAL HOURS“Death Rattle”
CONGESTION IN THE FINAL HOURS“Death Rattle”
• Positioning
• ANTISECRETORY: Scopolamine 0.3 - 0.6 mg SQ q1h prn Transdermal Gel (Taché Pharm.) 0.25 mg/0.1ml Give 0.5 mg q4h and q1h prn. Try 2-3 Transderm-V® Patches
• Consider suctioning if secretions are: distressing, proximal, accessible not responding to antisecretory agents
A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS
How do you know that the aggressive How do you know that the aggressive
use of opioids doesn't actually bring use of opioids doesn't actually bring
about or speed up the patient's death?about or speed up the patient's death?
0
10
20
30
40
50
60
70
80
90
100
Dyspnea Pain Resp. Rate (breaths/min)
O2 Sat (%) pCO2
Pre-Morphine
Post-Morphine
SUBCUTANEOUS MORPHINE INTERMINAL CANCER
Bruera et al. J Pain Symptom Manage. 1990; 5:341-344
Typically, with excessive opioid dosing one Typically, with excessive opioid dosing one would see:would see:
• pinpoint pupilspinpoint pupils• gradual slowing of the respiratory rategradual slowing of the respiratory rate• breathing is deep (though may be shallow) and breathing is deep (though may be shallow) and regularregular
COMMON BREATHING PATTERNS IN THE FINAL HOURS
COMMON BREATHING PATTERNS IN THE FINAL HOURS
Cheyne-Stokes
Rapid, shallow
“Agonal” / Ataxic
DON’T FORGET...For death at homeDON’T FORGET...For death at home
• Advance Directive: no CPR
• Letters (regarding anticipated home death) to:» Funeral Home» Office of the Chief Medical Examiner» Copy in the home
• physician not required to pronounce death in the home, but be available to sign death certificate