The Palliative Response
Comfort Care in the Last Hours of Life
Comfort Care in the Last Hours of Life
Admit to: (Appropriate Unit)
Diagnosis: (i.e. Metastatic Lung Cancer/Pain Crisis)
Condition: Grave
Status: Do Not Attempt Resuscitation (DNAR)
(DNAR terminology preferable to DNR)
Diet
Order a diet; patient may improve and desire to taste food
Full liquid instead of clear liquid (can advance if tolerate)
(More palatable, easier to swallow, less likely to cause aspiration)
May have food brought in by family
Allow patient to sit up for meals; assist to eat
Activity
Allow patient to sit in chair if desired and to use bedside commode
Allow family to stay in room with patient
Vital Signs
Minimum frequency allowed by policy
Limit notification orders to those necessary
Frequent monitors can alarm patient and family
Numbers can distract staff/family from patient
IV Considerations
Starting is often difficult and painful, frequently has no benefit for patie
Presence of edema indicates that patient is not dehydrated
Many patients have fluid overload, edema and pulmonary congestion
Oral hydration is a reasonable compromise. If IV fluids are used, suggest limited time trial, such as a 1000-1500 cc D51/2 NS over 6 hours.
Subcutaneous (SQ) Line
Small IV or butterfly needle inserted directly under the skin
(often on the abdomen or thigh)
For injecting small volumes of many medicines when oral route unavailable
Avoids burden of finding/maintaining IV access
Orders for Dyspnea
Oxygen 2-4 liters nasal prong; avoid face mask
Usually do not recommend monitoring oxygen saturation or telemetry
For persistent Dyspnea, use opioids, blow air on face with bedside fan turn, reposition, sit up. Nebs may be helpful
Hygiene
Avoid Foley catheter if possible (may be helpful for hygiene in select patients, e.g., obese or immobilized patient)
Diapers and cleansing may accomplish same thing
Delirious patient may pull on bladder catheters
Check all patients for impaction; suppository may be helpful
Consider evaluation by skin care nurse
Pain and Dyspnea
Opioids are usually the most effective in this setting
Calculate morphine equivalents used in recent past; adjust as needed
Usually stop sustained-released medicines and use immediate-release
Morphine concentrate 20mg/ml concentrate
Start with MS 5mg to much higher dose based on recent use q 2 hours
Offer—patient may refuse
Morphine Sulfate subq q2 hours (1/3 the oral dose)
Offer—patient may refuse
Pain, Dyspnea, Anorexia, Asthenia & Depression
Corticosteroid can have multiple beneficial effects
Less mineral-corticoid effect than Prednisone
Does not have to be given in multiple doses
Dexamethasone 4mg PO/SubQ breakfast and lunch
Nausea and Delirium (Phenothazines)
Haloperidol 2mg PO or 1mg SubC
Starting dose and q2 hours until settled; up to 3 doses for delirium
Increase frequency to q8-12 hours as needed
Nausea usually requires less frequent doses
Excellent antiemitic, helpful with delirium common at Life’s End
Anxiety and Seizures (Benzodiazepines)
Lorazepam 1mg PO/ SubC q6-8 hours prn
May be helpful with anxiety
Exercise care as delirium can sometimes be mistaken for anxiety
Effective against seizures only as IV or SQ and not PO
Death Rattle
Keep back of throat dry by turning head to side
Stop IV fluids or tube feeding, avoid deep suctioning
Scopolamine patch topical behind ear q3 days
(Atropine eye drops 2-3 in mouth q4 hours or till patch effective)
Yonkers might help with mouth care; family can cleanse with sponge sticks
Tips for Comfort and Safety
Reposition, massage, quietly sit with and speak to patient
Avoid sensory overload (e.g., TV); soft music instead
Use bed minder in lieu of restraints to alarm if patient gets up
Assisting Family
Advise about alerting other family members as to gravity of patient status
Facilitate family presence; order permission for family to visit or stay
Arrange visits of military relatives by contacting Red Cross
Arrange visits of incarcerated relatives by contacting warden
Give family the pamphlet Gone From My Sight
Notify Pastoral Care and Social Work of admission if appropriate
Avoid restraints
https://www.promotingexcellence.org/downloads/grantee_tools/bog4.pdf
Prior to 1 July 2015,
it was mandated
that diagnosis code Z51.5 Palliative care
was to be assigned only for episodes of care
with care type 30 Palliative care
and only as an additional diagnosis code.
The change included
in the Tenth Revision, Australian Modification (ICD-10-AM)
it was mandated
that diagnosis code Z51.5 Palliative care
was to be assigned only for episodes of care
with care type 30 Palliative care
and only as an additional diagnosis code.
The change included
in the Tenth Revision, Australian Modification (ICD-10-AM)
and the Australian Coding Standards (ACS) Ninth Edition
noted that diagnosis code Z51.5 Palliative care
could be assigned as an additional diagnosis
independent of the admitted patient care type.
As noted in ACS 2116 Palliative care,
palliative care or end of life care
is where the clinical purpose
or treatment goal
is optimisation of the quality of life
of a patient
with an active and advanced life-limiting illness.
The patient will have complex physical,
psychosocial and/or spiritual needs.
While a patient may require admission
to a hospital for the management
of an acute condition,
this does not mean
that they cannot also
be receiving palliative care
for an underlying condition
or disease.
Palliative care has always
been provided when required – irrespective
of care type,
but recording of this activity
has been masked until recently
by the coding standards.
noted that diagnosis code Z51.5 Palliative care
could be assigned as an additional diagnosis
independent of the admitted patient care type.
As noted in ACS 2116 Palliative care,
palliative care or end of life care
is where the clinical purpose
or treatment goal
is optimisation of the quality of life
of a patient
with an active and advanced life-limiting illness.
The patient will have complex physical,
psychosocial and/or spiritual needs.
While a patient may require admission
to a hospital for the management
of an acute condition,
this does not mean
that they cannot also
be receiving palliative care
for an underlying condition
or disease.
Palliative care has always
been provided when required – irrespective
of care type,
but recording of this activity
has been masked until recently
by the coding standards.
https://web.archive.org/web/20210122061440/https://www.health.qld.gov.au/__data/assets/pdf_file/0037/692956/techreport-18.pdf
Okay kan, Bro!
