THE FINAL DAYS

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THE FINAL DAY(S) Keeping the Promise of Comfort
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Cancer
Discontinued Dialysis
End-StageLung Disease
Stroke

• Bedridden
• Cant clear
• secretions
• Pneumonia
• Dyspnea, Congestion,
• Agitated Delirium

Post-99 Ischemic Encephalopathy
Neuro- Degenerative
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Main Features of Approach to Care

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

4
Patient Care Challenges in the Final Days

• Functional decline- transfers, toileting
• Cant swallow meds- route of administration
• Terminal pneumonia
• dyspnea
• congestion
• agitated delirium
• Concerns of family and friends

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Concerns of Patients, Family, and Friends

• 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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TALKING ABOUT DYING
Many people think about what they might
experience as things change, and they become
closer to dying. Have you thought about this
regarding yourself? Do you want me to talk about
what changes are likely to happen?
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• First, lets talk about what you should not
  expect.
• You should not expect
• pain that cant be controlled.
• breathing troubles that cant be controlled.
• going crazy or losing your mind

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If any of those problems come up, I will make
sure that youre comfortable and calm, even if it
means that with the medications that we use
youll be sleeping most of the time, or possibly
all of the time. Do you understand that? Is that
approach OK with you?
9
Youll find that your energy will be less, as
youve likely noticed in the last while. Youll
want to spend more of the day resting, and there
will be a point where youll be resting
(sleeping) most or all of the day.
10
Gradually your body systems will shut down, and
at the end your heart will stop while you are
sleeping. No dramatic crisis of pain, breathing,
agitation, or confusion will occur -
we wont let that happen.
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Which Came First....The Med Changes 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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Basic Medications in The Final Day(s)
SYMPTOM MEDICATION Pain
Opioid Dyspnea Opioid
Secretions Scopolamine Restlessness
Haloperidol Midazolam
or Lorazepam
Methotrimeprazine






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Basic Medications in The Final Day(s)
1. Opioid - pain, dyspnea 2. Antisecretory -
congestion 3. Sedative - restlessness, confusion
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Examples of Opioid Prescription / Orders In
Absence of a Protocol
Example 1 Morphine 5 - 20 mg po/SL/pr q4h. -
Start with 5 mg dose. Titrate or by 5 mg
. - Breakthrough the current q4h dose given q1h
prn. Example 2 Hydromorphone 0.5 - 2 mg/hr IV/SQ
sage. - Start with 0.5 mg/hr. Titrate or by
0.1- 0.2 mg/hr - Breakthrough the current
hourly dose q30 min prn.
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Sedation via SQ Route in Terminal Delirium
Moderate haloperidol 2.5 - 5 mg
SQ q4h plus q1h
prn midazolam 2.5 - 5 mg Severe haloperidol 5
mg
SQ q4h plus q1h prn midazolam 5 - 20 mg OR
SQ sage of haloperidol 1.25 mg/hr
midazolam 1.25 - 5 mg/hr
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Sedation in Terminal Delirium if No SQ Route
Available
Moderate lorazepam 1 - 2 mg
/ - SL q4h plus q1h prn
haloperidol 2.5 - 5 mg Severe lorazepam 2 - 4
mg / -
SL q4h plus q1h prn haloperidol 5 mg
Also consider chlorpromazine supps 50 - 100 mg pr
q4h
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CONGESTION IN THE FINAL HOURS Death Rattle

• Positioning
• ANTISECRETORY Scopolamine
• 0.3 - 0.6 mg SQ q1h prn
• Transdermal Gel (Taché Pharm.) 0.25 mg/0.1ml
• Give 0.5 mg q4h and q1h prn.
• Consider suctioning if secretions are
• distressing, proximal, accessible
• not responding to antisecretory agents

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DONT FORGET...For death at home

• Advance Directive no CPR
• Letters (regarding anticipated home death) to
• Funeral Home
• Office of the Chief Medical Examiner
• Copy in the home
• physician not required to pronounce death in the
  
• home, but be available to sign death
  certificate