Consider the response to supportive therapies and if there is a meaningful and sustained response to supportive treatments.
Predicting when somebody is going to die is often complex.
Signs of approaching death are picked up by the day-to-day assessment of deterioration, some but not all of the signs listed may occur:
- Diminished intake of food and fluids
- Difficulty swallowing medications
- Decreased level of consciousness
- Bed-bound/full nursing assistance required
- Apnoeic periods
- Peripheral cyanosis
- Cheyne-Stokes respirations
- Audible respiratory secretions
- Impalpable radial artery
- Mandibular movement on respiration
- Oliguria
https://bit.ly/2WNWrAs
families’ experiences of
end-of-life care in an acute setting
hindered family members’ engagement in decision-making
and involvement in their loved ones’ last days of life.
The absence of formal processes for
end of life (EOL) care planning
resulted in families being unprepared
for what they perceived
as their family member’s ‘sudden death’.
https://web.archive.org/web/20210627145022/https://www.ajan.com.au/archive/Vol35/Issue3/3Odgers.pdf
11 Tanda Orang Yang Mati Husnul Khotimah
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618185/pdf/nihms707994.pdf
Diagnostic Performance of 16 Clinical Signs for Impending Death in 3 Days (n=357)
Clinical Signs for Impending Death in 3 Days
- Palliative performance scale ≤20%
- Richmond Agitation Sedation Scale ≤−2
- Urine output over last 12 h <100 ml
- Death rattle
- Respiration with mandibular movement
- Peripheral cyanosis
- Cheyne Stokes breathing
- Pulselessness of radial artery
- Decreased response to verbal stimuli
- Decreased response to visual stimuli
- Non-reactive pupils
- Drooping of nasolabial fold
- Hyperextension of neck
- Inability to close eyelids
- Grunting of vocal cords
- Upper gastrointestinal bleed
https://bit.ly/2Ws75Oo
Drug Therapy for Anxiety in Palliative Care
https://bit.ly/DrugTherapyforAnxietyPC
“actively dying” or “imminent death”
- Confirm treatment goals; recommend stopping treatments that are not contributing to comfort – pulse oximetry, IV hydration, antibiotics, finger sticks, etc.
- Communicate clearly to others what is going on. Write in progress notes: “patient is dying,” not “prognosis is poor”.
- Treat symptoms/signs as they arise: common among these are: oral secretions, delirium, dyspnea, fever, and pain.
- Provide excellent mouth and skin care.
- Provide daily counseling and support to families.
The term ‘dying’ is used in reference to the terminal phase of life, where death is imminent and likely to occur within days or hours and occasionally weeks. This is sometimes referred to as ‘actively dying’.Gurgly / noisy breathing
https://web.archive.org/
Dying patients are often unable to clear their respiratory tract secretions by coughing and swallowing. This results in gurgly or noisy breathing. The level of evidence to support the use of anticholinergics in drying terminal secretions is poor, and palliative care practice relies on re-positioning the patient. However, if a medicine is deemed necessary use hyoscine butylbromide and review for effect.
- > Starting dose: hyoscine butylbromide 20mg by subcutaneous injection every two to four hours as required.
- > Commence treatment early and evaluate the response. Cease therapy if ineffective after three consecutive doses.
https://www.sahealth.sa.gov.au/
Download materi:
https://bit.ly/kolaborasiperawatanpaliatif
Interprofessional collaboration occurs when health professionals from different disciplines work together to identify needs, solve problems, make joint decisions on how best to proceed, and evaluate outcomes collectively.
https://pubmed.ncbi.nlm.nih.gov/20925291/
Interprofessional collaboration supports patient-centred care and takes place through teamwork.
https://pubmed.ncbi.nlm.nih.gov/20925291/
Palliative care involves an interprofessional collaborative approach in working with patients and their families and caregivers by providing patient-centered and individualized pain relief compassion, caring, and overall minimization of symptom severity.
https://austinpublishinggroup.com/palliative-care/fulltext/apc-v1-id1006.php
Because palliative care patients most often also have one or more chronic illnesses, the need for the interprofessional practice model is even more important.
https://austinpublishinggroup.com/palliative-care/fulltext/apc-v1-id1006.php
This type of collaborative care is often referred to as “comfort” care or “end-of-life” care, with the focus being on improving quality of life for both the patient, family, and both family and non-family caregivers.
https://austinpublishinggroup.com/palliative-care/fulltext/apc-v1-id1006.php
In particular, the limits of information sharing have been pointed out as important barriers to the quality of inter-professional collaboration
https://www.oatext.com/inter-professional-communication-in-palliative-care-general-practitioners-and-specialists-in-switzerlandc.php#gsc.tab=0
Interdisciplinary collaboration and teamwork are necessary components for collaborative communication to occur between team members in a hospice admissions setting.
https://symbiosisonlinepublishing.com/palliative-medicine-care/palliative-medicine-care16.php
Team interactions require trust, confidence and an equal effort by all team members.
https://symbiosisonlinepublishing.com/palliative-medicine-care/palliative-medicine-care16.php
Effective communication can be achieved through collaborative communication between team members in Interdisciplinary Team (IDT) meetings and research has been done to support this concept.
https://symbiosisonlinepublishing.com/palliative-medicine-care/palliative-medicine-care16.php
For patients who are not taking any regular analgesia:
☛ Start at an appropriate step of the analgesic ladder.
☛ If pain is persisting or increasing this should prompt a step up the ladder.
☛ If pain is severe then it is good practice to start at step 3, i.e. strong opioids.
☛ Be aware that significant renal impairment (usually eGFR <30) will change your choice of analgesic.
The usual starting doses on each step are:
- o Step 1: paracetamol 1g PO qds
- o Step 2: codeine 30mg-60mg PO qds (note steps 1 and 2 may be combined as co-codamol 30mg/500mg two tablets qds)
- o Step 3: immediate release morphine 5mg-10mg every 4 hours OR modified release morphine (e.g. Zomorph capsules or MST continus tablets) 10mg-20mg every 12 hours.
Which of the following is true with regards to cancer related anorexia and cachexia management?Adjuvant Analgesic in Pain Management of Palliative Care
https://bit.ly/AdjuvantAnalgesicPC
- A. Dexamethasone may help improve appetite and weight gain
- B. Progestins may help improve appetite and muscle growth
- C. Cannabinoids increase caloric intake and weight gain
- D. All of the above
- E. None of the above ✔(Answer)
Making decisions
- When and if to discontinue disease treatment
- When to remove life-support machines, such as ventilators and dialysis machines
- Where to receive hospice care
- What support the family needs to provide care for the dying person
- How best to enable the dying person to spend quality time with family and friends
- What emotional and spiritual support is wanted by the person who is dying, family members and friends
https://www.mayoclinic.org/healthy-lifestyle/end-of-life/in-depth/cancer/art-20047600
SIGNS OF IMPENDING DEATH AND SYMPTOMS IN THE LAST TWO WEEKS OF LIFE
- Abdominal swelling /Ascites
- Agitation
- Anorexia
- Anxiety
- Bed bound
- Bowel problems (not constipation or diarrhea)
- Cachexia
- Candidiasis
- Confusion
- Constipation
- Cough
- Cyanosis of extremities
- Dehydration
- Depression
- Diarrhea
- Dry mouth
- Dysphagia
- Dyspnea
- Edema
- Falls
- Fatigue
- Fever
- Hallucinations
- Hemoptysis
- Hemorrhage
- Incontinence
- Increased sleeping
- Mouth sores
- Myoclonus
- Nausea/vomiting
- Oral problems
- Pain
- Paralysis
- Pruritus
- Respirations with mandibular movement
- Respiratory secretions
- Sedation
- Seizures
- Skin integrity problems
- Sleep problems
- Urinary problems
- Weakness
- It's distressing to learn that a loved one is reaching the end of their life, but knowing what to expect can make it less upsetting for all involved.
- Pain is a complex symptom; there are several types of pain and numerous potential causes. Pain is also extremely personal and unique to the person experiencing it. For these reasons, pain management is also complex and deeply personal.
- Anxiety is a common symptom in patients nearing death. Some patients may experience mild anxiety, but for others, full-blown panic attacks can occur. Regardless of the cause, anxiety needs to be treated promptly.
- Anorexia results in weight loss that is primarily of fat but can include loss of muscle. If caught early on, anorexia may be treated and weight loss reversed with nutritional supplements or increased consumption of food.
- Nausea—an unpleasant feeling in the stomach that may or may not be followed by vomiting—is very common as a patient moves toward the end of life.
- Constipation occurs frequently in patients near the end of life. Cancer patients may have the highest prevalence, with as many as 70 percent to 100 percent of patients experiencing constipation at some point during their disease.
- If a patient experiences dyspnea at the end of life and is awake to feel it, the palliative medicine or hospital provider will be sure to relieve them from this symptom, usually by using certain medications to keep them unconscious.
- Terminal restlessness is a particularly distressing form of delirium that sometimes occurs in dying patients. It is characterized by anguish (spiritual, emotional, or physical), restlessness, anxiety, agitation, and cognitive failure.
- Altered levels of consciousness, such as when a patient is lethargic or comatose, for example, can also impair a patient's ability to clear his or her airway. Thus, the patient's secretions build up and cause a loud, rattling sound when air passes through the airway.
https://www.verywellhealth.com/the-death-rattle-1132474
SYMPTOM ASSESSMENT ACRONYM
O Onset
P Provoking / Palliating
Q Quality
R Region / Radiation
Where is it? Does it spread anywhere?
S Severity
What is the intensity of this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Right now? At best? At worst? On average? How bothered are you by this symptom? Are there any other symptom(s) that accompany this symptom?
T Treatment
What medications and treatments are you currently using? How effective are these?
Do you have any side effects from the medications and treatments?
What medications and treatments have you used in the past?
U Understanding / Impact on You
What do you believe is causing this symptom?
How is this symptom affecting you and / or your family?
V Values
What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)?
Are there any other views or feelings about this symptom that are important to you or your family?
PALLIATIVE CARE
The WHO (2012) states that “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.
PALLIATIVE APPROACH
An approach to care that does not attempt to lengthen or shorten the client’s life. It acknowledges death is drawing near, although this may be many months or even years away. The approach also recognises that a range of symptoms may need to be addressed to improve overall comfort during life and around the time of death. (DoHA 2006)
THE BENEFITS OF PALLIATIVE CARE
The benefits of palliative care
- have now been shown in multiple clinical trials,
- with increased patient and provider satisfaction,
- equal or better symptom control,
- more discernment of and honoring choices about place of death,
- fewer and less intensive hospital admissions
- in the last month of life,
- less anxiety and depression,
- less caregiver distress,
- and cost savings.
The cost savings come from cost avoidance,
or movement of a patient from
a high cost setting to a lower cost setting.
PMID: 24641562 DOI: 10.1146/annurev-publhealth-032013-182406
THE MULTIDISCIPLINARY TEAM
The importance of the multidisciplinary team:
There are many aspects
to the provision of palliative care
in the community that require
a multidisciplinary team approach
as the problems that can arise are often complex
and require the involvement of a number of people.
The main aim of the multidisciplinary team is
to meet the needs of the palliative care client.
The multidisciplinary team approach can also be used
to provide support to: carers, and individual team members.
Agreed goals of management are required to maximise
the effectiveness of a multidisciplinary team.
https://www.pallcaretraining.com.au/mod/page/view.php?id=346
MULTIDISCIPLINARY TEAM
A multidisciplinary team consists
of a mix of health care disciplines.
Team members share common goals,
collaborate and work together
in the planning and delivery of care.
Members of a multidisciplinary team
might include
· GPs,
· surgeons,
· medical
· or radiation oncologists,
· palliative care specialists,
· pastoral care workers,
· nurses,
· social workers,
· occupational therapists,
· physiotherapists,
· dieticians,
· volunteers,
· pharmacists
· or care assistants.
Ookay kan, Bro!
IKA SYAMSUL HUDA MZ
