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Preparing for the Predictable Planning for common threats to comfort in the final days. Tamara Wells RN MN CNS Dr. M. Harlos Medical Director WRHA Palliative Care Program Disclosures • No conflicts of interest • Many thanks to all the members of my team and others for their insights and help with this presentation. Objectives • To review some of the common predictable symptom scenarios at end of life • To review both pharmacologic and nonpharmacologic symptom management strategies • To discuss how end of life care is a team effort Death in the PCH • Residents live ~2.2 yrs post-admission - 82% died in the PCH - Diagnoses (Approx. 3 co-morbidities/death certificate) Cardiovascular 67% Dementia 41% Infectious diseases 30% Cerebrovascular 24% Metabolic 17% Cancer 10% (K Klassen, S Wowchuk. WRHA chart audit, 2002) Illness Trajectories Sudden Death Steady Decline/Expected Death Steady Decline with Crises Field & Cassel, 1997 Common Signs • Functional decline • transfers, toileting, eating • • • • Difficulty swallowing medications Fatigue and decreased activity tolerance Increased presentation of symptoms Concerns of family and friends Who is the team? Family Nurses/ Health Care Aides Patient Recreation/ Housekeeping Allied Health Partners Common Symptoms 1. 2. 3. 4. 5. 6. 7. Shortness of Breath Confusion/Delirium Pain Loss of Appetite & Dehydration Constipation Nausea & Vomiting Secretions LTC End of Life Pathways Dyspnea - Assessment Resident describes air hunger/breathlessness Or Resident unable to describe dyspnea but exhibits evidence of respiratory distress: • Increased work of breathing • Increased respiratory rate • Using accessory muscles • Agitated, restless, fearfulness Non-Pharmacological Management • • • • • • • Position sitting upright Cool air (fan or open window) Oxygen for alert resident (& hypoxic) Pace or minimize activity Light bed covers, loose clothing Good mouth care Quiet music, calm presence, distraction Pharmacological Management Medication Indications Route Starting Dose Frequency Morphine Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual 2.5-5mg q4h + q1h prn Subcut 1.252.5mg q4h + q1h prn Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual 0.5-1mg q4h + q1h prn Subcut 0.250.5mg q4h + q1h prn hydroMorphone (Dilaudid ®) Delirium - Assessment • Acute onset of global cognitive impairment related to general medical condition with: • • • • • • • Fluctuating consciousness Disorientation Disrupted sleep-wake cycle Reduced attention Perceptual disturbances Disorganized thinking Paranoid ideation The Confusion Assessment Method (CAM) 1. Acute onset 2. Inattention 3. Disorganized Thinking 4. Altered Level of Consciousness 5. Disorientation 6. Memory Impairment 7. Perceptual Disturbances 8. Psychomotor Agitation and Retardation 9. Sleep/Wake Cycle Disturbance 1 and 2 + 3 or 4 Delirium - Assessment • If clinically appropriate & consistent with goals of care- assess & treat potentially reversible causes of delirium such as: • • • • • • Infections Adverse medication effects Metabolic abnormalities Pain Urinary retention Hypoxia Management Is the resident agitated, restless or demonstrating responsive behaviours? NO Hypoactive Delirium • Sedation not indicated • Provide general comfort measures • Support family Management Is the resident agitated, restless or demonstrating responsive behaviours? YES=Hyperactive Delirium • • • • • • Non-pharmacological Keep a calm and reassuring presence Decrease environmental stimuli Pace or modify activity Monitor other factors that can impact comfort (constipation, urinary retention) Communicate with the team and family Encourage sips of fluid Pharmacological Management Medication Haloperidol (Haldol®) Methotrimeprazine (Nozinan®) Indications Agitated delirium – Pathway A Route Starting Dose Frequency Oral or sublingual 0.5-1 mg q6-8h prn + q1h prn Subcut 0.5-1 mg q6-8h prn + q1h prn 5mg q6-8h + q1h prn 5-25mg for severe agitation q6-8h + q1hprn Agitated Delirium Oral/subling Pathway A Nausea and Vomiting /subcut Pathway D Delirium Monitoring • Reassess every 24 hours or sooner depending upon response • Consider increasing dosages dependent upon starting dose • Consider stopping Haldol and moving to methotrimeprazine if delirium non-responsive to initial therapies Noisy Secretions Non-pharmacologic treatment • Noisy secretions present AND distressing to resident and/or family • 1st: Try repositioning. “Best side” • Oral suction? Only if visible oral or posterior pharyngeal secretions • No deep suctioning Pharmacological Management Is the Resident alert? YES • Glycopyrrolate 0.2-0.4mg subcut q2h PRN • If secretions persist: consider using a scheduled dose of glycopyrrolate 0.20.4mg subcut q6h & q1h PRN NO • Scopolamine 0.3-0.6mg subcut q1h PRN • If secretions persist: consider using a scheduled dose of scopolamine 0.30.6mg subcut q4h & q1h PRN Pharmacological Management Medication Glycopyrrolate Scopolamine Indication Noisy secretions Pathway C Noisy secretions Pathway C Route Subcut Subcut Starting Dose Frequency 0.2-0.4 mg q2hprn If secretions persist, q6h + q1h prn 0.3-0.6 mg q1hprn If secretions persist, q4h + q1h prn Noisy Secretions - Monitoring • Review secretions management every shift – Effective: • Continue present treatment • If receiving scheduled doses of glycopyrrolate or scopolamine, consider switching to prn only – Ineffective: • Maximize doses and schedule of antisecretory medications • Reevaluate positioning of the Resident • Support the family Pain • Pain may be related to medical complications • Pain may be related to chronic conditions • If pain exists it should be treated until end of life • Dying of itself is not painful Pain Assessment • • • • • • • Ask the patient (verbal indicators) Observe the patient (non-verbal indicators) Talk to family Investigate the medical history Present pain medications Standardized reporting PQRST – Provoking factors, Quality of pain, Relieving factors, Severity and Timing Assessment Tools Assessment Tools Pain Assessment and Management Patient already on Opioids • If prn only consider scheduled • Change long-acting to short acting equivalents • Use q4h dosing for already scheduled short acting • Increase opioid factor by 20-100% dependent upon context • Monitor for best route Patient not on Opioids • Start with the lowest dose • Start with the longest interval • Monitor regularly • Use breakthrough opioid when indicated Pain-Pharmacologic Management Medication Indications Route Starting Dose Frequency Morphine Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual 2.5-5mg q4h + q1h prn Subcut 1.25-2.5mg q4h + q1h prn Oral/sublingual 0.5-1mg q4h + q1h prn Subcut 0.25-0.5mg q4h + q1h prn hydroMorphone Dyspnea (Pathway B) (Dilaudid®) Pain (Pathway D) Pain-Nonpharmacologic Management • • • • • • • Pace and prepare for activity Use distraction and diversion Communicate between team members Decrease environmental stimuli Provide for spiritual/psychosocial support Reassure the patient/family Manage hydration when able Assessment • Review every 24 hours • Pain not controlled if >3/24 hours • Pain controlled alert and less than <3 breakthrough doses/24hrs • Monitor for over sedation – If not using breakthrough but sedated consider dose reduction of 20-50% Sedation vs. Euthanasia Dr. M. Harlos 03/12/14 When Death is Near Declining energy and alertness Decreasing intake of food and fluids Difficulty swallowing Mottling of the extremities Changes in breathing pattern Decreased urine output Return to basic reflexes When should you ask for help? • Symptom control not being achieved • Disagreement between team members • Feeling uncertain about the steps you are taking • Goals of care have been unclear • Help with conversion of medication • other Who can you call? • WRHA Palliative Care Program – 204-237-2400 – A Clinical Nurse Specialist or Physician will be able to assist Questions/Comments Resources 1. Long Term Care Website: http://home.wrha.mb.ca/prog/pch/EndofLifeCareEducationHandouts.php 2. Canadian Virtual Hospice: http://www.virtualhospice.ca 3. WRHA Palliative Program: 204-237-2400 4. Hospice and Palliative Care Manitoba for volunteer visiting and grief support Phone: 204-889-5825