Care in the final days

disclosures

outline

• where do people die in BC?
• how can you predict when death is near?
• preparing families for death
• death in different environments
• medication tips

Can I leave?

Death Predictors at the bedside

death rattle/secretion buildup

mandibular breathing (RMM)

peripheral cyanosis

radial pulses

preparation

"I was not expecting this!"

What is normal in dying?
*more sleep
*decline in po intake
*less responsiveness
*incontinence

Get family involved

• Encourage mouth/skin care
• Ask for direction re: spiritual and cultural needs
• Assist w positioning/turns

dying in the er

45 m with gi bleed

• met HCC with portal HTN/varices
• no palpable bp in ambulance
• spouse is RN
• patient awake

Untitled Slide

Quick deterioration

• profound hematochezia and projectile hematemesis
• staff in distress as to what to do
• rapid reinforcement of GOC with spouse
• comfort care direction clear

priorities

• monitors off
• private space if possible
• dark towels/suction
• fentanyl
• midazolam

community death

what is different

• + often the GOC are well established (home DNR/home death paperwork)
• +nursing care established
• +familiar environment
• +more space for family
• +privacy

what is different

• -less equipment
• -fewer med options
• -family stress when end is near
• -unlikely to have continual care
• -cultural differences with death in the home

72 f with met colon cancer

• pps 40 for last month
• pps 20 for last few days
• been followed by home RN for 5 weeks with near daily visits
• becoming more confused, poor po intake, low grade fever

more complications

• secretions++
• poor sleep
• moaning
• loss of po route

Son flies in>
"Call the ambulance"

on call rn arrives

• sc hydromorphone commenced
• sc methotrimeprazine
• sc glycopyrrolate
• pr acetaminophen

conclusion

• EHS arrives-patient more comfortable and remains at home
• Dies peacefully 72 hours later
• Bereavement services follow

final hours meds

• convert most away from oral route
• streamline medication burden
• focus on opiates, antiemetics, antisecretory meds, anti delirium meds, anticonvulsants/benzodiazepines

secretions

• discuss fluid balance
• assess patient position
• glycopyrrolate 0.1-0.4 mg sc q 6 h
• scopolamine/atropine may cross BBB
• avoid deep suctioning

terminal distress

• Methotrimeprazine-for more sedation. May require higher dosing*
• Haldol-perhaps less sedating
• Benzodiazepines

consider intranasal

double effect

take aways

• death may be predictable
• families need preparation
• dying may be different in different environments
• may need to be resourceful
• consider other routes
• prepare for double effect questions

questions