Final Hours - Coalition for Compassionate Care of California

Final Hours - Coalition for Compassionate Care of California

The Final Hours of Life Michael GuntherMaher MD, FACP Palliative Care and Hospice Kaiser-Permanente, Sacramento MGM/Adapted from EPEC 1 Objectives Describe symptoms seen in the final hours of life Address some of the common myths about dying Explore the role of spiritual care as death approaches MGM/Adapted from EPEC 2 How do you know its near the end? Tempo of illness

Changes are noticeable from week-to-week or day-to-day Escalating symptoms Pain is increasing despite changes in medication Nausea, vomiting and breathlessness that keep the person in bed No food or fluid intake Sleeping most of the day and night The patient says Im ready, Im close MGM/Adapted from EPEC 3 What are the physiological changes?

Pain Breathlessness Weakness Loss of appetite Altered heart, lung and kidney function Loss of thirst Delirium Death rattle MGM/Adapted from EPEC 4 Symptom

Edmonton PCS Canada St Christophers UK Memorial Sloan-Kettering USA Weakness 90 91 74 Loss of appetite

85 76 44 Pain 76 62 64 Nausea 68 44

44 Constipation 65 51 35 Sedation / confusion 60 N/A 60 Breathlessness

12 51 24 Symptom prevalence ina cancer population. Portenoy et al. Qual of Life Res. 1994; 3:183-189. MGM/Adapted from EPEC 5 Symptoms in the last 48 hours of life Symptom Frequency Rattling breathing 56%

Pain 51% Restless / agitated 42% Breathlessness 22% Lichter I, Hunt, E. J of Palliative Care 1990 MGM/Adapted from EPEC 6 Myths about Dying Pain will escalate Patients suffer from hunger or thirst

IV fluids improve comfort Artificial nutrition improves wellbeing Moaning is a reliable sign of discomfort MGM/Adapted from EPEC 7 Pain Myth: pain increases in final hours Body is shutting down Perception of pain diminishes Opioid needs typically decrease Increasing opioids may worsen delirium Continuous opioids are helpful in known pain syndromes Low urine output is a risk for toxicity Change drugs or lower the dose MGM/Adapted from EPEC

8 Breathlessness Occurs in 75% of dying patients Unusual respiratory patterns are typical Opioids are the best therapy Relaxes respiratory muscles May improve blood flow through lungs Decreases the brains sense of air hunger Other ways to help Fan Supplemental oxygen in some cases MGM/Adapted from EPEC 9 Weakness Most common complaint of the dying

Most difficult to treat Multifactorial Changes in central nervous system and endocrine systems Altered heart and kidney function How to help Presence Death in the preferred surroundings Drugs: glucocorticoids, methylphenidate MGM/Adapted from EPEC 10 Loss of Appetite The first basic need to disappear May occur weeks or months before death Cause of dismay for family Myth: tube feedings will improve wellbeing

Bloating, aspiration, swelling Prolonged dying Feeds the cancer as well How to help Educate the family Offer food the patient may want MGM/Adapted from EPEC 11 Altered heart, lung and kidney function

Expected Decreased urine output Low blood pressure Low oxygen levels Cool, pale or blue skin Supplemental IV fluids and oxygen dont reverse or relieve symptoms well MGM/Adapted from EPEC 12 Loss of thirst Occurs days before death in most cases Myth: IV fluids improve comfort Pulmonary congestion, tissue swelling are common IV fluids more likely to prolong dying than relieve symptoms How to help

Educate the family Oral swabs MGM/Adapted from EPEC 13 Delirium The most common, distressing symptom to watch Features Altered levels of alertness Altered sleep-wake cycles Delusions & hallucinations Moaning

Agitation Many potential causes Underlying disease Alterations in nervous system and body chemistry Medications (especially opioids) MGM/Adapted from EPEC 14 Delirium Treatment Happy delirium Do we need to treat it? Agitation, paranoia Antipsychotics Reduction in opioid use if possible May need SNF or hospital if too much for family

MGM/Adapted from EPEC 15 Spiritual Experiences Sometimes interesting to witness Speaking about or to others already dead I want to go home Intact hearing even when seeming to be asleep MGM/Adapted from EPEC 16 Two roads to death Confused Tremulous Restless

THE THE SYMPTOMATIC SYMPTOMATIC ROAD ROAD Hallucinations Normal Normal Mumbling Delirium Sleepy Myoclonic Jerks Lethargic THE

THESIMPLE SIMPLE ROAD ROAD Seizures Obtunded Semicomatose Comatose Dead Dead 17 Death rattle Causes Secretions in the airway Too weak to move or cough

Lung fluid from heart failure or infections Bothers the family How to help Scopalamine patches Atropine drops Suction in severe cases only MGM/Adapted from EPEC 18 When Death Occurs Signs no breath or pulse A time to stop and take in what has happened When the family is ready Call hospice Call 911 if hospice is not involved Tell operator the death was expected No CPR (there should be a POLST already)

Which hospital or morgue the body will go to Dispose of medications, especially opioids MGM/Adapted from EPEC 19 MGM/Adapted from EPEC 20

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