Caring for Elders in Their Final Days: Maintaining Dignity

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Caring for Elders in Their Final Days
Maintaining Dignity Comfort

• Karen A. Kehl, RN, PhD, ACHPN

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Approach To Care

• Perceptive and vigilant regarding changes
• Proactive communication with resident and
• family
• anticipate questions and concerns
• be available
• dont present non-choices as choices
• Aggressive pursuit of comfort
• Dont be caught off-guard by predictable problems

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Concerns Of Family

• How could this be happening so fast?
• What about food fluids?
• Things were fine until that medicine was
• started!
• Isnt the medicine speeding this up?
• Too drowsy!
• Too restless!
• Weve missed the chance to say goodbye
• What will it be like? How will we know?

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Which Came FirstThe Medication Change or the
Decline
Steady decline
Accelerated deterioration begins,medications
changed
Rapid decline due to illness progression with
diminished reserves. Medications questioned or
blamed.
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The Perception of the Sudden Change
When reserves are depleted, the change seems
sudden and unforeseen. However, the changes had
been happening.
Melting ice diminishing reserves
Day 1
Day 3
Day 2
Final
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Food and Fluid Issues

• Distinguish between prolonging living and
• prolonging dying
• Parenteral fluids not usually needed for comfort
• Pushing calories in terminal phase does not
• improve function or outcome
• We cant just let him die
• Not letting him die implies that you can make
  him live, which is not the case. The living vs.
  dying outcome is dictated by the disease, not by
  what you or the family decides to do.

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Basic Palliative Medications Used During Dying
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Pain at the End-of-Life

• How do you observe or assess for pain when
  non-verbal?
• Do they still need pain medication if they are
  unconscious or unresponsive?
• Will giving pain medication hasten their death?
• How can you administer pain medication when they
  dont swallow?
• Can all pain be controlled at the end of life?

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PAINAD Pain Assessment IN Advanced Dementia
(Warden, Hurley, Volcier, 2003)
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Pain Management Dosing

• Provide an around the clock baseline dose
• Oral method is preferred if it is available
• PCAs effective if available
• Have breakthrough or rescue dosing for times of
  acute pain
• 1/10 to 1/6 of total 24 hour dose
• Available every 1-2 hours

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Does Morphine Hasten Death?
USE OF SQ MORPHINE IN DYING PATIENTS Bruera et
al. J Pain Symptom Manage. 1990 5341-344
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Typical Symptoms With Opioid Overdose

• pinpoint pupils
• gradual slowing of the respiratory rate
• breathing is deep (though may be shallow) and
  regular

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Common Respiratory Patterns In Active Dying
Cheyne-Stokes
Rapid, shallow
Agonal / Ataxic
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Administration of Medications When the resident
Cannot Swallow

• Some meds come in solutabs (morphine sulfate,
  lorazepam)
• These will dissolve under the tongue or between
  the cheek and gum and are absorbed through the
  buccal membrane.
• They may be dissolved with a small amount (0.1cc)
  of water in a needleless syringe then inserted
  into the mouth
• While there is no strong research evidence of
  effectiveness, hospices routinely give oral meds
  via a rectal route.
• Medications are absorbed by the GI membranes.
• Time release meds may leave a shell that needs
  to be removed
• If the oral route is not available, IV is the
  most accurate route
• Need orders for IV meds
• Use PCA to provide small baseline dose with
  ability for staff to give bolus
• Instruct family NOT to bolus patient (lock out
  family)
• Transdermal meds are not accurate in the final
  days
• Circulation to the skin is altered
• Dying person is frequently diaphoretic and this
  affects absorption

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Non-pharmacological Methods of Pain Management

• Physical
• Hot and cold
• Massage therapy
• Cognitive/behavioral therapies
• Relaxation
• Guided imagery
• Complementary
• Therapeutic touch
• Music therapy
• Aromatherapy

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Case study

• What type of pain is this?
• What type of medication would you expect?
• With the baseline dose given, is morphine sulfate
  10mg po every 1-2 hours an appropriate
  breakthrough dose?
• Are there any other medications you would want?
• What other (non-pharmacological treatments) might
  be helpful?

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Dyspnea

• Incidence 70 during last 6 weeks
• Reuben DB, Mor V. Dyspnea in terminally ill
  cancer patients. Chest 198689(2)234-6.
• Treatment
• Pharmacological
• Low dose morphine
• Benzodiazepine, usually lorazepam
• Oxygen if it makes patient more comfortable
• Non-pharmacological
• Positioning
• Fans

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Secretions (Death Rattle)

• Positioning
• Medication
• Scopolamine
• Try 2-3 Transderm-V Patches
• Levsin
• Atropine
• Not preferred due to SE
• Consider suctioning if secretions are
• distressing, proximal, accessible
• not responding to antisecretory agents

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Terminal Restlessness

• Definition
• agitated delirium in a dying patient,
  frequently associated with impaired
  consciousness and multifocal myoclonus Burke,
  1997
• Indicators of terminal restlessness
• Frequent non-purposeful motor activity
• Inability to concentrate or relax
• Disturbances in sleep-rest patterns
• Fluctuating levels of consciousness, cognitive
  failure and/or anxiety
• Potential progression to agitation Kuebler,
  1997

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Factors Influencing Delirium
Bruera Neumann, 1998
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Terminal Restlessness Management

• Assess for causes
• Pain
• Alcohol or tobacco withdrawal
• Full bladder or bowels
• Pharmacological treatment
• Haloperidol or Chlorpromazine
• Midazolam or Propofol

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Depression

• What is true depression vs. despair, withdrawal,
  normal grief?
• When to treat?
• Who should be a part of this care team?

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Assessment Single question

• Are you feeling down, depressed or hopeless most
  of the time over the last 2 weeks?
• Accurate 55-100 of the time
• Chochinov, H.M, Wilson , K, Enns, G, et al. "Are
  you depressed?" Screening for depression in the
  terminally ill. Am J Psychiatry 1997 154(5)
  674-676.

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Grief versus Depression

• PREPARATORY GRIEF is grief that the ill person
  experiences when thinking about separation from
  this world.
• Common and normal
• Includes
• rumination about the past
• withdrawal from family/friends
• periods of sadness, crying or anxiety
• DEPRESSION Clinically significant depression
  among a population of dying patients may be
  somewhat more common (25-77) than in the general
  population.
• Not an inevitable part of the dying experience
• It is very treatable
• Somatic symptoms may be hard to distinguish from
  symptoms of illness
• Anorexia
• weight changes
• constipation
• Key differentiating factors include
• Feelings of guilt
• Hopelessness
• Worthlessness
• Suicidal ideation

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Distinguishing Grief from Depression

• Temporal variation
• Self image
• Hope
• Anhedonia (inability to feel pleasure)
• Response to support
• Active desire for an early death

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Care Team for Mood Disorders

• Physician
• Nurse
• Social Worker
• Chaplain
• Bereavement counselor
• Others (psychiatrist, psychologist, etc.)

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Pharmacological Treatment of Depression

• Tricyclic antidepressants
• Amitriptyline (Elavil), doxepin (Sinequan),
  imipramine (Tofranil), despiramine (Norpramin),
  nortripyline (Pamelor), clomipramine
  (Anafranil)
• Effective in 70 of patients
• Side effects unpleasant
• Dry mouth
• Drowsiness
• Constipation
• Dizziness
• 2-4 week response time (only useful if prognosis
  is gt1 month)

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Pharmacological Treatment

• SSRIs
• Paroxetine (Paxil), fluoxetine (Prozac),
  sertraline (Zoloft), citalopram (Celexa)
• Less side effects than tricyclics
• Minor orthostatic hypotension
• Urinary retention
• Sedation
• N, V, D
• Response time
• Fluoxetine (Prozac) 5-6 weeks (not very useful at
  end of life)
• All others 7-14 days (most often used at end of
  life)
• For elders or terminally ill start at lowest dose
  and increase as needed

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Pharmacological treatment

• Psychostimulants
• Dextroamphetamine (Dexedrine), methylphenidate
  (Ritalin, Concerta), pemoline (Cylert)
• Rapid onset and effects
• Good for prognosis lt4 weeks
• Counters sedative effect of opioids
• May be used to bridge time until SSRI is
  effective
• Side effects
• Stimulation
• Anxiety
• Insomnia
• Confusion

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Non-pharmacological Treatment

• Psychotherapeutic intervention
• Interpersonal interventions
• Behavioral interventions
• Complementary therapies
• Guided imagery
• Art and music therapy
• Humor
• Aromatherapy
• Massage therapy

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Skin Integrity at the End-of-Life

• Pressure ulcers more common in cancer patients
• Changes at the end of life such as
• Decreased nutritional intake
• Dehydration
• Incontinence
• Concentrated urine
• Immobility
• Sensory loss
• Change in circulatory status

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Skin Integrity Issues

• How does EOL condition affect skin care?
• What is the Kennedy Terminal Ulcer?
• What about repositioning, activity, mobility?
• What should be our goal with pressure ulcer
  healing, prevention, etc?
• Describe skin changes as the elder is dying
  (color, moisture, circulation).

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Kennedy Terminal Ulcer

• Usually pear-shaped
• On sacrum
• Usually red, yellow and/or black
• Sudden onset - Occurs overnight
• May initially appear as blackish abrasion
• Usual treatment for pressure ulcers is used
• Not usually reversible
• Individual usually dies within four days of onset
  of Kennedy Terminal Ulcer

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Goals of Care for Pressure Ulcers

• In the final days there are two primary goals
  concerning pressure ulcers
• Minimizing pain
• Preventing infection

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Repositioning, Activity, Mobility

• In the final days activity, repositioning, etc.
  should be based on the residents comfort
• Families often wish for increased activity
• This will NOT improve the outcome
• It will fatigue the resident more rapidly
• Must balance importance of repositioning with
  comfort
• If turning causes pain and pressure ulcer does
  not, may decrease repositioning
• May need to use low air loss bed if both ulcer
  and repositioning are painful

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Skin Changes at the End-of-Life

• Skin often becomes discolored
• Dusky
• Pale
• Red, blue or purple
• Mottling
• Often progresses up body
• Skin often becomes clammy as resident experiences
  diaphoresis
• Skin temperature may be cool even when resident
  has high body temperature
• Do not use heating pads or electric blankets

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Preparing the Resident and Family

• Outline what signs and symptoms indicate imminent
  dying
• Tell what they should NOT expect
• Uncontrolled pain
• Uncontrolled dyspnea
• Losing control
• Then tell what to expect
• Approaching signs