End of Life Care

1

• End of Life Care

2
Aged care end of life issues

• When does the end of life begin?
• Where should the end of life occur?
• What is best practice end of life care?
• What is needed to support this?

3
Pain management in end of life care

• Pain is a symptom that can occur in the last days
  of life
• Where pain is a pre-existing symptom, measures
  should be in place to ensure continued effective
  management during the end of life
• If pain is not a present problem, an intermittent
  (PRN) analgesic is ordered in anticipation of
  pain presenting.

4
Care context

• The end of life goal is that the individual be
  pain free
• Regular assessment is needed
• When pain is assessed, ordered analgesia is
  administered, and effectiveness determined
• Episodes of pain and its management are documented

5
Analgesia considerations

• If more than 3 PRN doses are given in a 24-hour
  period
• regular subcutaneous administration 4 hourly or a
  continuous subcutaneous infusion via syringe
  driver may be considered.
• if already on regular administration the dosage
  should be reviewed
• the PRN order is reviewed in line with
  alterations to regular doses

6
Other pain management issues

• Keep the individual and/or their primary carer
  informed about the care strategy
• Ensure that PRN medications are given in response
  to pain, or in anticipation of incident pain (eg,
  on moving)
• Ensure that the attending doctor is informed of
  any inadequacies in the pain management strategy

7
Other pain issues (2)

• Remember that any pain experience can be
  amplified by psychological and spiritual distress
• Maintaining general comfort measures will
  contribute to the overall management of pain

8
Review

• If the prescribed medications are ineffective a
  medical review is indicated.
• Escalating doses of opioids are not commonly seen
  in the last days of life, and should be regarded
  as an indication for urgent medical review
• Consult with the specialist palliative care
  service if indicated

9
Pain assessment in advanced dementia (PAINAD)
(Central Coast Adaptation)
10
Bibliography

• Anderson SL. Shreve ST. 2004 Continuous
  subcutaneous infusion of opiates at end-of-life.
  Annals of Pharmacotherapy. 38(6)1015-23
• Ellershaw J, Wilkinson S. 2003 Care of the Dying
  A pathway to excellence.
• Nauck F, Klaschick E, Ostgathe C. 2000 Symptom
  Control in the Last Three Days of Life. European
  Journal of Palliative Care 7(3) 81 - 84
• Regnard C, Hockley, J. 2004 A Guide to Symptom
  Relief in Palliative Care
• Twycross R, Wilcock A. 2001 Symptom Management in
  Advanced Cancer
• Wrede-Seaman LD. 2001 Treatment options to manage
  pain at the end of life. American Journal of
  Hospice and Palliative Care 18(2) 89-101, 144

11
Nausea / vomiting in end of life care

• Nausea is a symptom that may occur in the last
  days of life
• The causes of nausea / vomiting in the dying vary
  across diseases

12
Medication

• If nausea / vomiting has been an ongoing symptom
  prior to the last days of life then a regular
  anti-emetic is ordered together with PRN (as
  required) doses.
• If nausea / vomiting is not a present symptom,
  then an intermittent (PRN) anti-emetic is ordered
  in anticipation of nausea / vomiting presenting.

13
Care context

• The pathway goal is that the individual has no
  episodes of nausea / vomiting
• Nausea / vomiting is assessed regularly
• When an episode of nausea / vomiting occurs, the
  ordered anti-emetic is administered, and
  effectiveness determined
• Each episode is recorded in the progress notes

14
Review

• If the prescribed medications are ineffective a
  medical review is indicated.
• Consult with the specialist palliative care
  service if indicated

15
Bibliography

• Haughney A. 2004 Nausea vomiting in end-stage
  cancer. American Journal of Nursing 104(11)40-8
• Regnard C, Hockley J. 2004 A Guide to Symptom
  Relief in Palliative Care
• Woodruff, R. 2004 Palliative Medicine
• Cherny NI. 2004 Taking care of the terminally ill
  cancer patient management of gastrointestinal
  symptoms in patients with advanced cancer. Annals
  of Oncology 15(Suppl 4)iv205-13

16
Respiratory problems in end of life care

• Two respiratory symptoms that can occur during
  the dying process are excessive respiratory
  secretions and dyspnoea.

17
Respiratory secretions

• If excessive respiratory secretions are not a
  present symptom, an intermittent (PRN)
  antimuscarinic agent is ordered in anticipation
  of this symptom occurring.
• Hyoscine hydrobromide is a suggested medication,
  unless contraindicated.
• Repositioning can be effective in managing
  secretions.
• Suctioning is not usually used.

18
Respiratory secretions

• The noise associated with respiratory secretions
  can be a source of distress for carers, and
  additional explanation and reassurance may be
  indicated.
• In conscious patients glycopyrrolate (Robinal) or
  hyoscine butylbromide (Buscopan) may be preferred.

19
Respiratory distress

• Respiratory distress is managed in response to
  the underlying cause.
• Morphine (subcutaneous injection) has been shown
  to reduce dyspnoea without significant
  respiratory depression
• Anxiolytics (benzodiazepines) may reduce
  dyspnoea, especially where anxiety/ fear is a
  contributing factor.
• Oxygen may relieve the dyspnoea associated with
  hypoxia

20
Care context

• The care goal is that the individual has no
  episodes of respiratory distress or excessive
  respiratory secretions.
• Respiratory symptoms are assessed regularly.
• When an episode occurs, the ordered medication
  (or intervention) is administered, and
  effectiveness determined.
• Episodes are documented in the progress notes.

21
Review

• If the prescribed medications are ineffective a
  medical review is indicated.
• Consult with the specialist palliative care
  service if indicated

22
Bibliography

• Furst CJ, Doyle D. 2004 The Terminal Phase, in
  Doyle et al Oxford Textbook of Palliative
  Medicine (3rd Ed)
• Jennings AL, Davies AN, Higgins JPT, Broadley K.
  2001 Opioids for the palliation of breathlessness
  in terminal illness. The Cochrane Database of
  Systematic Reviews, Issue 3. Art. No. CD002066.
  DOI 10.1002/14651858.CD002066
• O'Donnell V. 1998 Symptom management. The
  pharmacological management of respiratory tract
  secretions. International Journal of Palliative
  Nursing 4(4) 199-203.
• Wildiers H, Menten J. 2002 Death rattle
  prevalence, prevention and treatment. Journal of
  Pain and Symptom Management 23(4) 310-7

23
Agitation / anxiety / restlessness in end of life
care

• Agitation / anxiety / restlessness are a group of
  symptoms that may occur in the last days of life
• The possible causes of agitation / anxiety /
  restlessness in the dying are many, and the exact
  cause will be evident in about 50 of cases.

24
Agitation / anxiety / restlessness

• Possible causes of agitation / anxiety /
  restlessness include
• physical discomforts (eg. pain, full bladder,
  pressure areas)
• anxiety and existential distress
• drug toxicity, hypoxia
• metabolic imbalance
• Where a clearly reversible cause is identified,
  intervention to reverse the cause is appropriate

25
Agitation / anxiety / restlessness

• If agitation / anxiety / restlessness is not a
  present problem, an intermittent (PRN) anxiolytic
  is ordered in anticipation of agitation / anxiety
  / restlessness presenting during the end of life
  period

26
Agitation / anxiety / restlessness

• If more than 3 PRN doses are given in a 24-hour
  period a more regular administration should be
  considered.
• Alternatively the substitution of a regularly
  administered long acting benzodiazepine (eg
  Clonazepam) may be appropriate.

27
Care context

• The care goal is that the individual has no
  episodes of agitation or restlessness
• Agitation / anxiety / restlessness is assessed
  regularly
• When an episode of agitation / anxiety /
  restlessness occurs, the appropriate nursing
  intervention or medication is administered, and
  effectiveness determined.
• Each episode is recorded in the progress notes

28
Review

• If the prescribed medications are ineffective a
  medical review is indicated.
• Consult with the specialist palliative care
  service if indicated.
• Occasionally agitation may be refractory to
  standard drug treatment.

29
Bibliography

• Brajtman S. 2003 The impact on the family of
  terminal restlessness and its management.
  Palliative Medicine 17(5) 454-60
• Ellershaw J. Wilkinson S. 2003 Care of the Dying
  A pathway to excellence
• Regnard C, Hockley J. 2004 A Guide to Symptom
  Relief in Palliative Care
• Twycross R, Wilcock A. 2001 Symptom Management in
  Advanced Cancer
• Travis S, Conway J. 2001 Terminal Restlessness in
  the Nursing Facility, Geriatric Nursing 22(6)
  308 - 312

30
Maintaining comfort in end of life care

• Providing comfort focused care is central to
  quality end of life care
• Maintaining comfort is the primary role of all
  staff attending a resident in the last days of
  life.

31
Care context

• A number of comfort measures are considered in
  end of life care. These include
• The need for a pressure relieving mattress
• The need for a single room (if an option)
• Key comfort care areas are
• Positioning Mouth care
• Eye care Skin care
• Micturition Bowel care

32
Mouth care

• The care goal is that the mouth and lips be clean
  and moist.
• Mouth care is reviewed regularly.
• Moist oral mucous membranes will tend to prevent
  thirst.
• Local protocols for cleaning mouth and dentures
  are used.
• Avoid alcohol based agents as these can
  exacerbation dryness

33
Positioning

• The care goal is that a comfortable position be
  maintained. Frequency of repositioning is
  reviewed regularly.
• Comfort should take priority over pressure
  relieving interventions that cause distress.
• Use individualspreferred position as often as
  reasonable.
• Use PRN analgesia in advance of repositioning
  when indicated

34
Eye care

• The care goal is that eyes are clean and moist
• Eye toilets following local practice are used
• Eye lubrication is indicated if eye is dry

35
Skin care

• The care goal is that skin is clean and moist
• Avoid products that dry or harm skin
• The need for pressure area care should be
  balanced against the need for comfort
• Wounds should be managed in the least invasive
  way (no time to heal)
• If incontinent ensure skin protection products
  are used

36
Micturition

• Care goal is that the individual be dry and
  comfortable. Urinary aids such as pads should be
  used if resident is incontinent
• Urinary output is reduced during the last days of
  life
• Urinary retention should be excluded if
  individual becomes restless
• Catheterisation is only used when it will improve
  overall comfort

37
Bowel care

• The care goal is that the individual is not
  agitated or distressed by constipation or
  diarrhoea.
• Optimal bowel care prior to the last days of
  life, especially in the presence of regular
  opioids, contributes to overall comfort.

38
Bowel care

• Bowel products lessen in quantity as the end of
  life approaches
• Once oral medications are not possible, in the
  last days of life, other bowel management agents
  are not usually used unless to reverse an
  identified problem.
• A full rectum should be excluded if the
  individual becomes restless (use suppositories).

39
Bibliography

• Glare P, Dickman A, Goodman M. 2003 Symptom
  Control in Care of the Dying, in Care of the
  Dying A pathway to excellence
• OConnor M, Aranda S. (Eds) 2003 Palliative Care
  Nursing A Guide to Practice
• Wright K. 2002 Caring for the terminally ill the
  district nurse's perspective. British Journal of
  Nursing 11(18) 1180-5

40
Spiritual / religious / cultural issues in end of
life care

• Understandings, expectations and practices
  relating to dying and death vary for each
  individual
• Quality end of life care needs to address what,
  if any, spiritual, religious or cultural factors
  are important for each individual and their
  immediate family during this time
• Identified needs are to be recorded and planned
  for wherever possible

41
Spiritual / religious / cultural care

• Relevant rituals / processes may apply
• Pre death
• At the time of death
• Post death
• Identifying these and facilitating their
  adherence will support the individual and their
  family

42
Spiritual / religious / cultural care

• Take an individual approach. Avoid assumptions
  and stereotyping.
• If indicated, facilitate the practice of
  identified rituals and provision of support.
• Utilise family contacts / resources.
• Negotiate the introduction of other pastoral
  resources if indicated.
• Exercise cultural awareness and make use of
  available resources.

43
Bibliography

• Hopper A. 2000 Spiritual care. Meeting the
  spiritual needs of patients through holistic
  practice. European Journal of Palliative Care
  7(2) 60-2.
• Neuberger J. 2004 Caring for Dying People of
  Different Faiths (3rd Ed)
• Speck, P. 2003 Spiritual / Religious Issues in
  Care of the Dying, in Care of the Dying A
  Pathway to Excellence
• Stanworth R. 2004 Recognising Spiritual Needs in
  People who are Dying
• Woodruff R. 2004 Palliative Medicine (4th Ed)