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Diagnosing Dying: Physiology & management For Specialists

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Diagnosing Dying: Physiology & management For Specialists Kyle P. Edmonds, MD Assistant Clinical Professor Doris A. Howell Palliative Care Service UC San Diego Health System Adapted from Palliative Care International Curriculum, Ed. Frank R. Ferris


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Overall message Diagnosis and management of dying is an overlooked aspect of medical care. The family’s perception of the process can have long-term consequences. Dying is not inherently uncomfortable. List the two high-risk end-of-life symptoms requiring specialist-level management.


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Anticipatory Guidance: Last Hours Everyone will die < 10 % suddenly Unique processes & risks Little experience


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Anticipatory guidance: Complicated bereavement Hx complicated bereavement Psych Hx / Dependent personality Out of life-cycle norms Poor social support Absent frame of reference Sudden/violent death


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Your Tools: Acetaminophen Bisacodyl Chlorpromazine Glycopyrrolate Lorazepam Morphine concentrate Senna Mrs. A


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A Note On Language Adapted from Fig 2: Hui et al, 2014.


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Principles of Management Diagnose Anticipatory guidance Environment Assessment Acknowledge Fears


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Adapted from : Ellershaw & Ward, 2003.


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Normalize the Environment Family presence Turn off monitors Minimize meds / procedures Stop oxygen Include pt in conversations Touch


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Assessment: Comfortable?


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Physiology of dying Cardiovascular Renal Respiratory Gastrointestinal HEENT Constitutional Neurological


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Vital Signs Adapted from Fig 1: Bruera et al., 2014.


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Constitutional Terminal fever Pressure ulcer risk Symptoms: Weakness; Fatigue; Joint position fatigue


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Fever Fears: Discomfort, Hastened death Management Noninvasive cooling Rectal acetaminophen


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Cardiovascular Tachycardia, hypotension Peripheral cooling, cyanosis Third-spacing Mottling of skin… Symptoms: dizziness, edema


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Mottling


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Renal Decreasing urine output Diminished GFR (changing pharmacokinetics) Symptom: generally comfortable


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Renal Clearance Morphine Liver Morphine ? M3G . . . ? M6G . . . Analgesia CNS + +++ +++ + Collins SL, et al. J Pain Symptom Manage. 1998. Mercadante S, Arcuri E. J Pain. 2004. Urine 90 – 95 %


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Pain: continuous opioids & Oliguria <20ml/hr (500ml/d): decrease <10ml/hr (250ml/d): stop! Always: bolus for symptoms


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Respiratory Patterns: Tachypnea, Apnea Chin-lift, jaw-jerk* Diminishing tidal volume Oropharyngeal secretions* Symptoms: generally comfortable


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Changes in respiration Fear: Suffocation, dyspnea Management Family support Oxygen variably effective Opioids (rarely)


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Secretions** Fear: Choking, Drowning Management Reassurance Positioning Glycopyrrolate


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Gastrointestinal Loss of ability to swallow Dehydration Ileus Sphincter dysfunction Symptoms: anorexia; nausea; dry mouth; incontinence


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Decreasing food intake Fear: Starvation, Hastened Death Management Normalize & Reframe Food for comfort Aspiration risk


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Patient/Family Meaning “Food” = ?


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Patient/Family Meaning No! “Food” =


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Decreasing fluid intake Fears: Thirst, Hastened Death Management Reassure Benefit/Burden of IVF Oral care


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Loss of sphincter control Fears: Indignity Management Education & Support Diligent cleaning / skin care Urinary catheters? Absorbent pads / surfaces


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HEENT Open eyes Loss of retro-orbital fat pad Insufficient eyelid length Slack Mouth Symptoms: dry eyes; dry mouth


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Xerostomia / Xerophthalmia Fears: Thirst, Discomfort Management Oral care Eye care


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Neurological Progressive decrease in LOC Preserved hearing & touch Delirium Pain not automatic! Symptoms: Confusion; Drowsiness


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Pain Fear: Uncontrolled pain Assessment Grimace Physiologic signs Incident vs. rest pain Differentiation from delirium


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Restless Confused Tremulous Hallucinations Mumbling Delirium Myoclonic Jerks Sleepy Lethargic Obtunded Semicomatose Comatose Seizures USUAL ROAD DIFFICULT ROAD Baseline Dead Neurological: Two roads to death


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Terminal delirium** Fear: Terror Management Early Diagnosis Education & expectations Environment Proportional sedation


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After death Cardiopulmonary arrest Eyes often open Pupils fixed Jaw open Waxen pallor Muscles, sphincters relax


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Pronouncing death “ Please come… ” Entering the room Pronouncing Documenting


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What to do when death occurs Who to call… not ‘ 911 ’ No specific ‘ rules ’ Rarely any need for coroner Consider traditions, rites, rituals


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Common Grief


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Bereavement care Bereavement care Attendance at funeral Follow-up to assess / support Assistance with practical matters


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Overall message Diagnosis and management of dying is an overlooked aspect of medical care. The family’s perception of the process can have long-term consequences. Dying is not inherently uncomfortable. List the two high-risk end-of-life symptoms requiring specialist-level management.


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References Cozzolino, P, J., Staples, A, D., Meyers, L, S., & Samboceti, J. (2004). Greed, Death, and Values: From Terror Management to Transcendence Management Theory. Personality and Social Psychology Bulletin, 30, 278-292. Ellershaw J & C Ward (2003). Care of the dying patient: The last hours or days of life. BMJ. 326:30-4. Fulton CL, Else R. Physiotherapy. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998:821-822. ISBN: 0192625667. Hwang IC, Ahn HY, Park SM, Shim JY, Kim KK. Clinical changes in terminally ill cancer patients and death within 48 h: when should we refer patients to a separate room? Support Care Cancer 2013;21:835e840. Hui D et al (2014). Concepts and definitions for “actively dying,” “end of life care,” “terminally ill,” “terminal care” and “transition of care”: A systematic review. J Pain Sympt Mgmt. 47(1): 77-89. Hughes AC, Wilcock A, Corcoran R. Management of “death rattle”. J Pain Symptom Manage. 12:271-272. PMID: 8942121. Full Text. Morita T, Tsunoda J, Inoue S, Chihara S. The Palliative Prognostic Index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 1999;7:128e133. Rushton CH, Kaszniak AW & JS Halifax (2013). Addressing moral distress: Application of a framework to palliative care practice. J Pall Med. 16(9): 1080-88. Shimizu et al. (2014). Care strategy for death rattle in terminially ill cancer patients and their family members: Recommendations from a cross-sectional nationwide survey of bereaved family members’ perceptions. J Pain Sympt Mgmt. 48(1): 2- Storey P. Symptom control in Dying. In: Principles and Practice of Supportive Oncology. Ed: A Berger, RK Portenoy, D Weissman. Lippincott-Raven Publishers, Philadelphia 1998;741-748. ISBN: 0397515596. Sykes N, Thorns A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med. 2003;163(3):341-4. PMID: 12578515. Full Text. Twycross R, Lichter I. The terminal phase. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998:977-992. ISBN: 0192625667. Weissman DE, Heidenreich CA.Fast facts and concepts #4 death pronouncement in the hospital. End of Milwaukee, WI: End of Life Physician Education Resource Center. Fast Facts Index. Full Text HTML. Full Text PDF.


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