Supportive Care for Dying in Final Days/Nursing Role in Facilitating a Home Death

Final Question: Pediatric Pain Assessment Tools - List 4

Numeric Scale

Poker Chip

Quest

Verbal pain assessment

FLACC

Neonatal Pain Assessment

Pediatric Pain Profile

NPass

Final Question: Discharge planning for unhoused clients - questions nurses should ask (List 2 Questions)

Do you have somewhere to stay tonight?

Do you have supports? Someone I can call to assist you?

Do you have an address for medication prescriptions?

Can I call the shelter for you?

Final Question: 4 Strategies to discuss death with children

Art, Mandala, Story Telling, Role Play, Support Group for teens, 3 Ws (Wishes, Worries, Wonders)

Final Questions: What are 4 different resources located in MB to refer families who lost a loved one

Palliative MB, livingoutloud.life, mygrief.ca, caringtogether.lfe

As the person is dying… (slide 13)

• encourage family to talk to the person even if they’re not responding or seeming to hear

• suggest they tell the dying person what they meant to them, how they’ll be remembered, and say their goodbyes

• Use role modelling in words and actions

• Encourage gathering of family members and grieving

What steps do you need to do before a palliative patient returns home? (slide 26)

• forms need to be completed

• did the patient fill out an EOL directive?

• Notification of anticipated death at home and direction from patient’s physician - 5 copies to…

  • local or regional EMS

  • funeral director

  • office of the Chief Medical Examiner or RCMP if death occurs in a location where there is no ME

  • keep one in the home

  • physician keeps 1 file

What to consider when patient is entering the dying phase (slide 28)

• reconfirm patient’s goals of care, preferred place of care, and what to do in an emergency

• connect with home nursing (already in place)

• ensure that required forms are completed (no CPR and/or notification of expected home death)

• get discontinuation of non-essential medication (explain and provide examples)

Arrange the following before sending a dying client home (slide 29)

• subcutaneous/transdermal/SL/IN medication administration when pt can no longer take PO

• arrange for hospital bed ± pressure relief mattress

• arrange for foley catheter as needed

• obtain an order for a SC anti-secretion medication (atropine, glycopyrrolate)

• standing orders for home death

Crisis Meds (slide 34)

hydromorphone, morphine, nozinan, lorazepam. scopolamine gel

Common breathing patterns - Cheyne-Stokes

(apnea) - brief pauses in breathing that become progressively longer (from a few seconds to a minute or more) as death approaches; alternating shallow breaths and apnea; <8RR/min

Common breathing patterns - Rapid, shallow

Tachypnea ?

Common breathing patterns - “Agonal”

irregular, gasping breaths that occur as the body’s systems begin to shut down

Common breathing patterns - Ataxic

unpredictable, chaotic sequence of shallow and deep breathing with random periods of apnea

Common breathing - Noisy Breathing

wet, gurgling sound caused by air moving over pooled secretions in the throat or airways; occurs when pt is too weak to swallow or cough effectively and may happen during inhalation or exhalation; terminal secretions/end stage-congestion can accompany agonal breathing —> groans, gurgles, or grunts on exhalation

Pooled Secretion and Anticholinergics

Anticholinergics are beneficial for preventing further pooling; repositioning can assist with natural drainage; these are distressing to hear but not a sign of suffering/pain/choking (reflects loss of airway control)

What’s a good death

freedom from pain, at peach with God, presence of family, mentally aware, tx choices followed

Physiological signs of impending death

• decreased urine output, dark tea coloured urine

• weakening pulse

• anxiety, restlessness, confusion, hallucinations AKA delirium

• fluctuating LOC with gradual decline (including awareness)

• dysphagia (death rattle), flaccid muscles

• changes in pattern and sounds of breathing - periods of apnea (Cheyne-Strokes), sound of congestion

• Progressive coldness, discolouration, mottling (starting from the feet and goes upward)

• dyspnea, congestion, agitated delirium

Routes for managing pain at EOL

1. SC medications, either continuation of previous opioid or initiation of low dose hydromorphone or morphine

2. Transdermal medications can be continued, but usually available in too high a dose to initiate at this time

3. Sublingual & subbuccal & intranasal

Dyspnea Tx

Pharm: hydromorphone, nozinan, lorazepam (benzodiazepines)

Non-Pharm: fan, open windows, tripod positioning

Home O2: if known to be hypoxic and O2 has assisted in the past and doesn’t increase restlessness; in dying phase, do not monitor O2 sats and may remove O2 as death approaches

Fluids Burden

Increase fluid can contribute to: edema, ascites, congestion, N/V

Complexity and discomfort associated with fluids may increase agitation

Increased need to void

Dehydration may act as a natural anesthetic

May prolong suffering and dying rather than living

Thirst can be addressed with good mouth care, hydration doesn’t prevent thirst

Fluids benefit

to treat OIN and hypercalcemia - need to assess with pt, family, and MD

Bereavement visit after a home death

agency dependant

ideally first visit approximately ~4 weeks after death

Second visit approximately 6 months after death

Appropriate educational materials for grief and bereavement; give resources to family

Excess Respiratory Secretion (Death Rattle)

can be distressing, prepare family for changes before they occur

median time from onset to death is 8-23 hrs

most common in patients with poor conditions, decrease LOC
If alert- pt may be anxious and fearful of suffocating

terminology is important

Respiratory Congestion

Pharm: Glycopyrrolate, Atropine, Scopolamine

Non-Pharm: avoid unnecessary fluids or deep suctioning; consider suctioning only if distressing, proximal, accessible; gurgle respirations = saliva over vocal chords

Delirium

Terminal restlessness, rule out any physical causes such as pain, urinary retention, or constipation

If cannot be reversed treat with

• neuroleptics: Nozinan (methotrimeprazine), haloperidol

  • benzodiazepines: lorazepam, midazolam

Nausea Pharm Tx

Metoclopramide, Haloperidol, Methotrimeprazine

Opioid Induced Neurotoxicity (OIN)

Potential fatal neuropsychiatric syndrome of: cognitive dysfunction, delirium, hallucinations, seizures/myoclonus (twitching of large muscles), pain (hyperalgesia/allodynia)

• early cognition is critical

• treatment: switch opioid, decrease opioid dose, hydrate (IV/subcut), nozinan, benzos for seizures