care of the imminently dying patient
DESCRIPTION
Presented to HPM Fellowship July 2010. Has handout also uploaded.TRANSCRIPT
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Care of the Imminently Dying Patient
July 8th, 2010
Christian Sinclair, MDKansas City Hospice & Palliative Care
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Prognostication of the Terminal Phase
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Working with Ranges - Minutes
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Working with Ranges - Hours
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Working with Ranges - Days
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Death Trajectories
• Sudden Death
• Death from Acute Illness
• Death from Chronic Illness
• After Withdrawal of Life Support
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Scales
• Palliative Performance Scale
• Palliative Prognostic Index
• Links available from:– prognosis.pallimed.org– EPERC Fast Facts
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The Rally
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What to Manage vs. What to Expect
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What to Manage vs. What to Expect
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Transforming from Patient-Centered Care to
Family-Centered Care
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Time and logistics
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Time and logistics
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Time and logistics
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Time and logistics
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Time and logistics
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Systems-Based Decline
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Examination of the dying patient
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Constitutional
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Eyes & Oropharyngeal
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Gastrointestinal
• Anorexia – Major family education point here – GI shut down – industrial analogy
• Cachexia – body image issues
• Decreased Fluid Intake – another major family education point
• Incontinence - dignity
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Cardiovascular• Hypotension
– Hypovolemic– Cardiogenic– Septic
• Poor cap refill, cyanosis, mottling, edema
• Brady / Tachycardia– possible sign of distress body adjustment
• Implantable Devices– think ahead about deactivation
• Don’t forget about blood pressure meds
• Major prognostic value in imminent death
• Can be fooled with variation
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Renal
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Pulmonary
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Skin Care
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Neurological/Psychological
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Considerations of Location
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Spiritual/Existential Considerations
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Medication Management
• Prognosis / Goal Mismatch– If not aligned then change the medications
• Pill Dysphagia- Think ahead for other options
• Alternate Routes– PR is not the only option– Topical medications – eh.
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Unexplained Prolongation of the
Terminal PhaseNo one has really looked at this
population but it bears some examination.
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For a copy of the slides, please email: [email protected]
• Recommended Reading/ Key References:
• Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3rd Ed.
• EPEC – Last Hours of Living, Module 12, 1999.
• Ferris FD, von Gunten CF, Emanuel LL. Competency in End-of-Life Care: Last Hours of Life. J of Pall Med. August 2003: 605-613.
• Plonk WM, Arnold RM. Terminal Care: The Last Weeks of Life. J of Pall Med 8(5): 1042-55