5 mins on last days of life and palliative care emergencies !

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5 mins on last days of lifeand palliative care
emergencies !

• Dr. Ros Taylor
• Hospice Director
• Hospice of St. Francis Berkhamsted
• June 2012

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Know who to ring !!!Know where the resources are
!

• Mount Vernon Cancer Network Advice 01923 844281
• Hospices.open all hours
• Peri-patetic Marie Curie Nurse
• OOH District Nurses

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Last moments of life

• Precious
• Very symbolic to be together
• Hours at bedside - focus on separation and
  memories

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Acknowledge death is near

• Fundamental to good management
• Allows symptom control and decisions
• Allows final business and acceptance
• If ignore closeness to death
• No care of dying
• Inappropriate treatment

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Surprise Question

• would I be surprised if this patient died in
  ..a few days ??

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Anticipate

• We can see the future..often

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Clinical intuition

• Declining mobility
• Distracted and distant
• Breathless
• Difficulty swallowing
• Circulation changes
• PEOPLE KNOW !!

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Limit treatment to

• Analgesia
• s/c diamorphine or morphine
• Sedation if needed
• s/c midazolam or levomepromazine
• Anticholinergic
• s/c glycopyrronium or hyoscine

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Just in Case Boxes

• 3-5 days of
• Analgesia
• Sedation
• Drying agent
• Anti-nausea

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Stopping medication

• Stop futile medication - treat symptoms only
• If unable to swallow - use parenteral route

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Syringe drivers

• When to use
• Unable to take oral medication
• Nausea and vomiting
• Dysphagia
• Unconscious
• What to use

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Fentanyl in the last days

• Keep patch on at same dose death
• Add extra analgesia as morphine in a driver

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The Pain of it all
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Managing terminal painContinue analgesia until
death

• If not swallowing
• then s/c infusion of diamorphine with 1/3 of
  previous oral morphine dose
• Breakthrough pain
• Use sixth of 24hr opioid dose
• If not had opioids
• Then 10 - 20mg diamorphine s/c per 24 hrs
• Plus anti-emetic

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Terminal Dyspnoea

• INSPIRE
• EXPIRE
• Powerful words

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When midazolam fails

• Short acting 1-3 hrs
• amnesic not analgesic
• in some people acts like alcohol
• increase agitation and aggression
• Alcohol and benzo use affects its activity
• try Nozinan or Phenobarbitone

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Terminal restlessness

• Look for reversible cause
• Bladder, bowel, pain, hypoxia
• Best drug is midazolam
• 2.5mg 5mg s/c midazolam
• 20 mg per 24 hrs midazolam
• Or lorazepam SL

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Sedation

• If you want to die in your sleep you have to
  sleep first..

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Liverpool Care Pathway for the Dying

• ?? Stairway to Heaven
• Or
• ?? Improve everyones care
• to a minimum standard

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Know who to ring !!!Know where the resources are
!

• Mount Vernon Cancer Network Advice 01923 844281
• Hospices.open all hours
• Peri-patetic HUC Marie Curie Nurse
• OOH District Nurses