Downloaded 524 times
Uploaded bypankaj rana
End of life care
This document discusses various topics related to end of life care, including palliative care, hospice care, end of life in the ICU, common symptoms at end of life, and their management. It addresses pain management, including assessment of pain and the WHO pain ladder. It also discusses management of other common symptoms like nausea/vomiting, dyspnea, fatigue, anorexia/cachexia, depression, delirium, and euthanasia. Important court cases related to passive euthanasia in India and other countries are also summarized.
More Related Content
End of life care
- 1. End of lifecare Presented by Pankaj Nurse Practitioner 2nd yr Moderator Dr. sushant Khanduri Associate professor
- 2. END OF LIFECARE Palliative Care Making life as easy as possible for patients and families living with serious illness Hospice care hospice care is given when there is life expectancy of 6 month or less
- 3. End of Lifein the ICU 10-20% of all ICU patients die Often illnesses are unanticipated – little previous discussion of illness with family Prognostication variable Culture of aggressive treatment Patients not generally able to participate
- 4. Five Most CommonSymptoms Pain Nausea/vomiting Breathlessness Weight loss Weakness / fatigue
- 5. Basics of PainManagement Use a pain scale WHO pain ladder Use standing doses, not PRN Always have a breakthrough pain plan 10% of daily opioid dose q 1-2 h Reassess dosage needs daily
- 6. Assessment of Pain PQRST P= Provoking/Palliating factors Q = Quality in patient’s own words R = Radiates S = Severity T = Time Recommended instruments: • McGill Pain Questionnaire (MPQ) and its short form (SF-MPQ)
- 8. WHO 3-step Ladder 1 mild(1-3) 2 moderate (4-6) 3 severe (7-10) Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants ASA Acetaminophen NSAIDs ± Adjuvants
- 9. Neuropathic Pain TricyclicAntidepressants (1 in 3 pts respond) ◦ Desipramine, other TCA’s, venlafaxine ◦ Use limited by CV adverse effects Gabapentin/Pregabalin (1 in 4 patients respond) ◦ usual effective dose 900–1800 mg / d; max may be > 3600 mg / d ◦ minimal adverse effects ◦ drowsiness, tolerance develops within days • Systemic administration of local anesthetics • Lidocaine or mexiletine effective in 30 RCT’s • Combination may be the most effective Brunnhuber, K., Nash, S., Meier, D.E., et al (2008
- 10. Bone pain Metastasis tobone ◦ 70% of pt with prostate, breast CA ◦ 30% of pt with thyroid, lung, bladder CA Multidisciplinary approach, including: Analgesics: opioids, NSAIDs Disease modifying therapy (chemotherapy, hormone therapy) Corticosteroids Bisphosphonates Radiopharmaceuticals (strontium, samarium) External beam radiation Orthopedic intervention External bracing
- 11. Depression Loss of socialposition, job, prestige, income Loss of role in family Insomnia, chronic fatigue Sense of helplessness Disfigurement Anger Bureaucratic bungling Delays in diagnosis unavailable physicians uncommunicative physicians Failure of therapy Friends who do not visit Total Pain Anxiety Fear of hospital or nursing home Fear of pain Worry about family and finances Fear of death Spiritual unrest, uncertainty about future Physical pain Other symptoms Adverse effects of treatment O'Neill, B., Fallon, M. BMJ 1997, 315p. 801-80
- 12. Nausea/Vomiting • Patients withcancer • 13-17% of terminally ill cancer patients in the last 1-2 weeks of life • 6-68% of all patients with cancer Patients with other illnesses: ◦ AIDS: 43% to 49% of patients ◦ Heart disease: 17% to 48% of patients ◦ Renal disease: 30% to 43% of patients Assessment: simple visual analogue scales or numerical rating scales
- 13. Cause Drug Examples V– Vestibular Cholinergic Histaminic Anticholinergic Antihistaminic Scopolamine Promethazine Diphen- hydramine O – Obstructive Cholinergic Histaminic 5HT3 Drugs stimulating the myenteric plexus Senna products M- Motile (dysmotility of upper gut) Cholinergic Histaminic 5HT3 Prokinetics (stimulating 5HT4 receptors) Prokinetics, metoclo- pramide I – infectious/inflam- matory Cholinergic Histaminic 5HT3 Neurokinin 1 Anticholinergic Antihistaminic 5HT3 antagonists Neurokinin 1 ant. Anti-inflammatory Scopolamine Promethazine Diphenhydramine Odansetron Apprepitant Corticosteroids Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)See handout for doses, cost Treat anxiety if present Management of nausea and vomiting
- 14. DYSPNEA Prevalence ◦ 17-30%of patients living with cancer ◦ 90-95% of end-stage COPD patients ◦ 60-88% of end-stage heart disease patients Increasingly common as the end of life approaches Best assessment is patient report
- 15. Recent ACPguidelines show evidence supports treatment with: ◦ Oxygen for hypoxemia Strong evidence for COPD & exercise ◦ Opioids Theoretical effect of respiratory depression not supported by the literature ◦ Beta-agonists for dyspnea from COPD Qaseem, A, Snow, V., Shekelle, P, et al. Ann Intern Med. 2008;148:141-146
- 16. Fatigue • Approximately 40%of cancer patients experience fatigue at the time of diagnosis • Worse during or after chemotherapy • Higher than 75% in patients with advanced cancer • Common with COPD, heart failure • Multifactorial • Best evaluated by self-assessment measures • No gold standard measurement available
- 17. Management of Fatigue Evidence supports use of: ◦ Psychological, psychoeducational interventions (small) ◦ Methylphenidate – small, significant improvement • Exercise - small improvement Energy conservation, activity management - small but significant effect No effect: progestational steroids, paroxetine, or multivitamins. Insufficient data to recommend any specific complementary therapies Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 18. Promote energyconservation Evaluate medications Optimize fluid, electrolyte intake Permission to rest Clarify role of underlying illness Educate, support patient, family Include other disciplines
- 19. Dexamethasone ◦ 4mgPO once daily ◦ feeling of well-being, increased energy ◦ effect may wane after 4-6 weeks ◦ continue until death Methylphenidate ◦ 5mg PO q 8AM and q noon ◦ May increase up to 20mg daily Do not give after 2pm to avoid interfering with sleep
- 20. Anorexia/Cachexia • Prevalence: 70%of patients with advanced cancer • Best assessment is patient report • Treatments: • Corticosteroids • Orally consumed supplements • Parenteral nutrition Brunnhuber, K., Nash, S., Meier, D.E., et al (2008)
- 21. NUTRITION • High caloriediet • High protein diet If patient cannot take orally. • Try enteral feeding( BEST FEEDING ) • And lastly parenteral nutrition
- 22. Management Family educationis key Tailor diet to patient preferences ◦ Fresh fruit Melon, grapes ◦ Things that are cold and sweet Ice cream ◦ Lemon drops, zinc lozenges for bad taste in mouth ◦ Most patients do not want dairy, fried foods Manage grief, disappointment about change in diet Encourage socializing at meal times even if patient does not want to eat
- 23. Depression Recent ACPGuidelines: ◦ Physicians should screen for and treat depression in patients facing end-of-life ◦ Evidence supports use of TCA’s and SSRI’s ◦ Psychosocial interventions also effective Some providers will use methylphenidate in patients with very short life expectancy Qaseem, A, Snow, V., Shekelle, P, et al. AnnIntern Med. 2008;148:141-146
- 24. Delirium • Prevalence: • 20%to 30% of people with cancer, COPD and end-stage liver disease in SUPPORT • 26% to 44% in terminal cancer • 83% in people during their final days. • Assessment: • Confusion Assessment Method (CAM) • Memorial Delirium Assessment Scale (MDAS) • Treatment in the terminally ill is difficult • Prevention is key
- 25. • Drugs arethe most common cause of delirium • reduction and possibly withdrawal of anticholinergic and psychoactive drugs • opioid dose reduction and/or rotation (usually at an equi analgesic dose with a reduction of 20% to 30%) • Newer antipsychotics no better than haloperidol
- 26. Pain Ratings For16 Common Hospital Procedures For 165 Subjects Urethral catheter Mechanical restraints Movement from bed to chair IM/SC injection None IV catheter Chest x-ray Vitals signs Transfer to a procedure Waiting for a test or procedure PO medications severe Arterial blood gas Moderate Central line placement Nasogastric tube Peripheral IV insertion Phlebotomy Mild Morrison et al, JPSM 1998
- 27. EUTHANASIA • Euthanasia isdescribed as the deliberate and intentional killing of a person for the benefit of that person in order to relieve him from pain and suffering • The term ‘Euthanasia’ is derived from the Greek words which literally means “good death” (Eu=Good; Thanatos=Death).
- 28. Types • Euthanasia canbe categorized into two types- active and passive (a)Active Euthanasia- When a person directly and deliberately does something which results in the death of patient. • It is considered crime in many country and in India but Netherlands, Belgium, Switzerland is sanctioned by the passage of “Termination of Life on Request and Assisted Suicide (Review Procedures) Act”
- 29. • Euthanasia canbe further classified as ‘voluntary’ where euthanasia is carried out at the request of the patient and ‘non-voluntary’ where the person is unable to ask for euthanasia (perhaps because he is unconscious or otherwise unable to communicate), or to make a meaningful choice between living and dying and a surrogate person takes the decision on his behalf.
- 30. Cases • Now weshall discuss two important judgments: Airedale case from the House of Lords, UK and Aruna Shanbaug case from Supreme Court of India giving us a fair idea regarding the evolution of the laws pertaining to Passive Euthanasia in India and the world. • irreversible coma or Permanent Vegetative State are indication of ethunasia
- 31.
- 32.
- 33. DNR (Do NotResuscitate) DNR (Do Not Resuscitate) is a clear concept in most developed countries. It involves not initiating resuscitation in the event of a cardiac or respiratory arrest.
- 34. CANDIDATES FOR DNR •Where life sustaining treatment is likely to be ineffective or futile. • -Where patient has prolonged unconsciousness which is unlikely to recover. • -Where patient has a terminal condition for which there is no definitive therapy. • -Where patient has a chronic debilitating disorder where burden of resuscitation far outweighs the benefits.
- 35. NOT THE CANDIDATESFOR DNR • Patient is unable to pay for advanced care. • Where the outcome is doubtful (may or may not improve situation). • Where there is conflicting opinion among the family members. • Where responsible next of kin is not available for discussion. • Where written consent is not available.
- 36. DNR procedure • Clearairway • Inotropic support • Provide Oxygen • Position for comfort • Splint • Control bleeding • Provide pain medication • Provide emotional support • nutrition
- 37. Not done inDNR • Perform chest compressions • Insert advanced airway • Administer Cardiac resuscitation drugs • Provide ventilator assistance including non invasive ventilation • Defibrillate
- 38. CARE OF DEADBODY DEAD BODY CARE After death the body undergoes many physical changes. So care must be provided as early to prevent tissue damage /disfigurement of body parts.
- 39. Purpose of deadbody care 1. To prepare the body for the morgue. 2. To prevent discoloration or deformity of the body. 3. To protect the body from post mortem discharge.
- 40. 1. Check ordersfor any specimens 2. Ask for special requests to family (eg: shaving , a special gown , Bible in hand ) 3. Remove all equipments , tubes , supplies and dirty linens. 4. Cleanse the body thoroughly , apply clean sheets 5. Brush and comb the hairs 6. The eyelids are closed and held in place for a few seconds , so they remain closed. 7. Dentures should be in the mouth to maintain facial alignment.
- 41. 8. Mouth shouldbe closed. 9. Remove all the ornaments. 10. Absorbent pads are placed under the buttocks to take up any feaces and urine released because of muscle sphincter relaxation 11. All the orifices should be closed. 12. Cover with a clean sheet up to the chin. 13. Spray a deodorizer to remove unpleasant odor. 14. Apply name tag ( wrist , right big toe) 15. Allow the family members to view the dead body 16. The body is wrapped in a large piece or plastic or cotton material used to enclose a body after death. Identification is then applied outside of the wrapper.
- 42. 17. Hand overall the belongings to the relatives. 18. Do complete documentation in the nursing notes. Time of death and actions taken to prevent the death. Who pronounced the death. Any organ donation Personal articles left on the body Personal items given to family Time of discharge and destination of the body Location of name tags on the body Special request by family 19. Hand over the dead body to the relatives / sent to the mortuary.
- 43.