Osteopathic EPEC Module 12

1
Osteopathic EPEC
Education for Osteopathic Physicians on
End-of-Life Care
Based on The EPEC Project, created by the
American Medical Association and supported by the
Robert Wood Johnson Foundation. Adapted by the
American Osteopathic Association for educational
use.
American Osteopathic Association AOA Treating
our Family and Yours
2
Module 12

• Last Hours of Living

3
Last hours of living

• Everyone will die
• lt 10 suddenly
• gt 90 prolonged illness
• Last opportunity for life closure
• Little experience with death
• Exaggerated sense of dying process

4
Prognostication

• Skill of prediction and art of communication
• When?
• Advise in terms of ranges
• hours to days
• days to weeks
• weeks to months

5
Preparing for the last hours of life . . .

• Time course unpredictable
• Any setting that permits privacy, intimacy
• Anticipate need for medications, equipment,
  supplies
• Regularly review the plan of care

6
. . . Preparing for the last hours of life

• Caregivers
• Awareness of patient choices
• Knowledgeable, skilled, confident
• Rapid response
• Likely events, signs, symptoms of the dying
  process

7
Module 12, Part 1

• Physiological Changes, Symptom Management

8
Objectives

• Assess and manage the pathophysiologic changes of
  dying
• Care for the whole person, not just the symptoms

9
Physiologic changes during the dying process

• Increasing weakness, fatigue
• Decreasing appetite / fluid intake
• Decreasing blood perfusion
• Neurologic dysfunction
• Loss of ability to close eyes
• Pain

10
Weakness / fatigue

• Decreased ability to move
• Joint position fatigue
• Increased risk of pressure ulcers
• Increased need for care
• Activities of daily living
• Turning, movement, massage, OMT

11
Decreasing appetite / food intake

• Fears giving in, starvation
• Reminders
• food may be nauseating
• anorexia may be protective
• risk of aspiration
• clenched teeth express desires, control
• Help family find alternative ways to care

12
Decreasing fluid intake . . .

• Oral rehydrating fluids
• Fears dehydration, thirst
• Remind families, caregivers
• Dehydration does not cause distress
• Dehydration may be protective

13
. . . Decreasing fluid intake

• Parenteral fluids may be harmful
• Fluid overload, breathlessness, cough, secretions
• Mucosa / conjunctiva care

14
Decreasing blood perfusion

• Tachycardia, hypotension
• Peripheral cooling, cyanosis
• Mottling of skin
• Diminished urine output
• Parenteral fluids will not reverse

15
Neurologic dysfunction

• Decreasing level of consciousness
• Communication with the unconscious patient
• Terminal delirium
• Changes in respiration
• Loss of ability to swallow, sphincter control

16
Frequency of symptoms last two weeks of life

• Pain (51-100)
• Dyspnea (22-46)
• Asthenia (80)
• Anorexia (80)
• Dry mouth (70)
• Mental confusion (68)

17
Signs of active dying

• Retained audible respiratory secretions - death
  rattle (24-60 hours)
• Respirations with mandibular movement (jaw
  movement increases with breathing) (2-5.8 hours)
• Cyanosis of extremities (1-5 hours)
• No radial pulse (1-3 hours)

18
2 roads to death
THE DIFFICULT ROAD
Confused
Tremulous
Restless
Hallucinations
Normal
Mumbling Delirium
Sleepy
Myoclonic Jerks
Lethargic
Seizures
Obtunded
THE USUAL ROAD
Semi-comatose
Comatose
Dead
19
Decreasing level of consciousness

• The usual road to death
• Progression
• Eyelash reflex

20
Communication with the unconscious patient . . .

• Distressing to family
• Awareness gt ability to respond
• Assume patient hears everything

21
. . . Communication with the unconscious patient

• Create familiar environment
• Include in conversations
• assure of presence, safety
• Give permission to die
• Touch the power of touch can provide comfort,
  caring

22
Terminal delirium

• The difficult road to death
• Medical management
• Benzodiazepines
• lorazepam, midazolam
• Neuroleptics
• haloperidol, chlorpromazine
• Seizures
• Family needs support, education

23
Changes in respiration . . .

• Altered breathing patterns
• diminishing tidal volume
• apnea
• Cheyne-Stokes respirations
• accessory muscle use
• last reflex breaths

24
. . . Changes in respiration

• Fears
• Suffocation
• Management
• Family support
• Oxygen may prolong dying process
• Breathlessness

25
Loss of ability to swallow

• Loss of gag reflex
• Buildup of saliva, secretions
• Scopolamine to dry secretions
• Postural drainage
• Positioning
• Suctioning

26
Loss of sphincter control

• Incontinence of urine, stool
• Family needs knowledge, support
• Cleaning, skin care
• Urinary catheters
• Absorbent pads, surfaces

27
Pain . . .

• Fear of increased pain
• Assessment of the unconscious patient
• Persistent vs fleeting expression
• Grimace or physiologic signs
• Incident vs rest pain
• Distinction from terminal delirium

28
. . . Pain

• Management when no urine output
• Stop routine dosing, infusions of morphine
• Breakthrough dosing as needed (prn)
• Least invasive route of administration

29
Loss of ability to close eyes

• Loss of retro-orbital fat pad
• Insufficient eyelid length
• Conjunctival exposure
• Increased risk of dryness, pain
• Maintain moisture

30
Medications

• Limit to essential medications
• Choose less invasive route of administration
• Buccal mucosal or oral first, then consider
  rectal
• Subcutaneous occasionally
• Intravenous rarely
• Intramuscular almost never
• Add intravenously, rarely

31
Medical futility

• Wont achieve the patients goal
• Serves no legitimate goal of medical practice
• Ineffective more than 99 of the time
• Does not conform to accepted community standards

32
Physiologic Changes and Symptom Management

• Summary

33
Module 12, Part 2

• Expected Death

34
Objectives

• Prepare, support the patient, family, caregivers

35
As expected death approaches . . .

• Discuss
• Patient / family wishes
• Status of patient
• Realistic care goals
• Role of physician / interdisciplinary team
• What patient experiences ? what onlookers see

36
. . . As expected death approaches

• Reinforce signs, events of dying process
• Personal, cultural, religious, rituals, funeral
  planning
• Family support throughout the process

37
Counsel about palliative care interventions

• Be clear about intent of intervention
• We would like to increase his morphine dose
  because we are concerned that he might be
  experiencing some pain (or shortness of breath).
• Inquire as to understanding of action and
  concerns
• What is your understanding of the proposed
  actions. Do you have any concerns?

38
Counsel about palliative care interventions

• Address spoken (and unspoken) concerns
• We do not believe this action will hasten
  death, nor is this the intent.
• Our goal is to enable him to die a natural and
  peaceful death, letting it unfold at its own
  pace.

39
Signs that death has occurred . . .

• Absence of heartbeat, respirations
• Pupils fixed
• Color turns to a waxen pallor as blood settles
• Body temperature drops

40
. . . Signs that death has occurred

• Muscles, sphincters relax
• Release of stool, urine
• Eyes can remain open
• Jaw falls open
• Body fluids may trickle internally

41
Telephone notification of death

• Inquire as to where the person is and whether
  alone (if driving while on a cell phone, advise
  the person to pull over and park)
• Identify self, relationship to the deceased
  (physician/nurse on-call), give brief advanced
  alert (Im sorry I have some bad news.) and give
  the news
• Listen more than you speak. If questions arise,
  answer them briefly. For more detailed inquiries,
  reassure the caller that these can be answered
  later.

42
Telephone notification of death

• Do NOT say that the person must come in right
  away give permission to let feelings settle
  suggest coming in with a family member or friend
• Give clear instructions as to where to go and
  whom to contact when arriving at the hospital,
  home or facility
• Finish with an empathic statement, such as This
  must be very hard for youPlease let me know if
  there is anything else I can do to help.

43
After expected death occurs . . .

• Care shifts from patient to family / caregivers
• Different loss for everyone
• Invite those not present to bedside

44
. . . After expected death occurs

• Take time to witness what has happened
• Create a peaceful, accessible environment
• When rigor mortis sets in
• Assess acute grief reactions

45
Moving the body

• Prepare the body
• Choice of funeral service providers
• Wrapping, moving the body
• Family presence
• Intolerance of closed body bags

46
Other tasks

• Notify other physicians, caregivers of the death
• Stop services
• Arrange to remove equipment / supplies
• Secure valuables with executor
• Dispose of medications, biologic wastes

47
Bereavement care

• Bereavement care
• Attendance at funeral
• Follow up to assess grief reactions, provide
  support
• Assistance with practical matters
• Redeem insurance
• Will, financial obligations, estate closure

48
Dying in institutions

• Home-like environment
• Permit privacy, intimacy
• Personal things, photos
• Continuity of care plans
• Avoid abrupt changes of settings
• Consider a specialized unit

49
Expected Death

• Summary

50
Module 12, Part 3

• Loss, Grief, Bereavement

51
Objectives

• Identify, manage initial grief reactions

52
Loss, grief with life-threatening illness . . .

• Highly vulnerable
• Frequent losses
• Function / control / independence
• Image of self / sense of dignity
• Relationships
• Sense of future

53
. . . Loss, grief with life-threatening illness

• Confront end of life
• High emotions
• Multiple coping responses

54
Loss, grief, coping

• Grief emotional response to loss
• Coping strategies
• Conscious, unconscious
• Avoidance
• Destructive
• Suicidal ideation

55
Normal grief

• Physical
• Hollowness in stomach, tightness in chest, heart
  palpitations
• Emotional
• Numbness, relief, sadness, fear, anger, guilt
• Cognitive
• Disbelief, confusion, inability to concentrate

56
Complicated grief . . .

• Chronic grief
• Normal grief reactions over very long periods of
  time
• Delayed grief
• Normal grief reactions are suppressed or postponed

57
. . . Complicated grief

• Exaggerated grief
• Self-destructive behaviors eg,
  suicide
• Masked grief
• Unaware that behaviors are a result of the loss

58
Tasks of the grieving

• Accept the reality of the loss
• Experience the pain caused by the loss
• Adjust to the new environment after the loss
• Rebuild a new life

59
Assessment of grief

• Repeated assessments
• Anticipated, actual losses
• Emotional responses
• Coping strategies
• role of religion
• Interdisciplinary team assessment, monitoring

60
Grief management

• If reactions, coping strategies appropriate
• Monitor
• Support
• counseling
• rituals
• If inappropriate, potentially harmful
• rapid, skilled assessment, intervention

61
Loss, Grief, Bereavement

• Summary