end of life symptom management dec 3, 2014 mudit dabral rosene pirrello
TRANSCRIPT
End of Life Symptom Management
Dec 3, 2014Mudit Dabral
Rosene Pirrello
Understand concept of death
Identify & manage common symptoms
Objectives
Everyone will die
<10% suddenly
>90% prolonged illness
Time course unpredictable
Need to review the plan regularly
Last Hours of Living
Affirms life
Regards dying as a normal process
Neither hastens nor postpones death
Relieves symptoms
Palliative Care
Integrates medical, psychological & spiritual aspects of care
Is often a support system to patients & family
Palliative Care
Anorexia (loss of appetite)
Cachexia (Weight loss)
Gradual Symptoms
Medications Depression Nausea Dysphagia Odynophagia Any advance disease
Anorexia & Cachexia
Reversible causes –Medications side effectsPainNauseaConstipationDepression
Anorexia & Cachexia
Lift dietary restrictions Environmental pleasantries Socialization Small portions Oral hygiene
Anorexia - Cachexia
Metoclopramide
Magesterol acetate
Anorexia - Cachexia
? Given up
? Not fighting
Fatigue
Little is known about Pathophysiology & treatment
Fatigue
Reversible Causes: Medications Dehydration Anemia Electrolyte imbalance Suboptimal sleep
Fatigue
Give patient permission to rest
Clarify the role of underlying disease
Fatigue
Steroids
Dexamethasone (2-20mg/d)
Psychostimulants (methylphenadate 2.5-15 mg q AM & noon)
Fatigue
Medications Decreased motility Impaction Mechanical obstruction Dehydration Metabolic (Hypercalcemia, Hypokalemia)
Constipation
Treat the cause
Laxatives - Stimulants, Osmotic
Prokinetics
Constipation
Nausea, vomiting
Pain
Hospitalized patients: 14%-56% Dying patients 80%-90%
Terminal Delirium
End of Life
Can contribute to complicated & prolonged grief disorder
Diminishes opportunity for closure of relationships
Terminal Delirium
Reversible 50% Pain Constipation Urinary retention Hypercalcemia, Hepatic failure, Hypoxia Infection Dehydration Medications
Delirium
Major organ failure
Hypoxic encephalopathy
Terminal Delirium
Create a familiar environment
Reassure family
Give permission to die
Touch
Treatment - Terminal Delirium
Benzodiazepines - Lorazepam, Midazolam
Neuroleptics - Haloperidol, Chlorpromazine
Treat seizures
Treatment - Terminal Delirium
Dyspnea Altered breathing patterns Low tidal volume, Cheyne-Stroke respirations Accessory muscle use Last few reflex respiratory efforts “Death rattle”
Respiratory Changes
Fears – Suffocation
Support family
Oxygen may prolong dying process
Purpose of treatment is relief of unpleasant sensation.
Respiratory Changes
Opioids (MS2.5 -20mg) Steroids (prednisone 10-20mg 3x a day,
Dexamethasone 8 mg per day) Anxiolytics (Lorazepam 0.5-2mg q 6 hrs) Diuretics Bronchodilators Anticholinergics (scopolamine patch,
Glycopyrrulate 1 mg-2mg q 6-8hrs )
Dyspnea - Treatment
Care in the last hours is
as important as at any other time in life
Overall Message
QUESTIONS?