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The. EPEC-O. TM. Education in Palliative and End-of-life Care - Oncology. Project. The EPEC-O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation. - PowerPoint PPT Presentation
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The EPEC-O Curriculum is produced by the EPECTM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.
Education in Palliative and End-of-life Care - Oncology
The
ProjectEPEC-O
TM
EEPPEECC
OO
EEPPEECC
OO
Module 6Module 6Last Hours of Living
Module 6Module 6Last Hours of Living
EPEC – Oncology Education in Palliative and End-of-life Care - Oncology
EPEC – Oncology Education in Palliative and End-of-life Care - Oncology
Overall messageOverall message
Care in last hours is as Care in last hours is as important as at any other time important as at any other time
in cancer carein cancer care
Care in last hours is as Care in last hours is as important as at any other time important as at any other time
in cancer carein cancer care
ObjectivesObjectives
Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers
Assess, manage the Assess, manage the pathophysiological changes of dyingpathophysiological changes of dying
Pronounce a death and notify the Pronounce a death and notify the familyfamily
Prepare, support the patient, family, Prepare, support the patient, family, caregivers caregivers
Assess, manage the Assess, manage the pathophysiological changes of dyingpathophysiological changes of dying
Pronounce a death and notify the Pronounce a death and notify the familyfamily
VideoVideo
Last hours of livingLast hours of living
Everyone will dieEveryone will die
< 10% suddenly< 10% suddenly
> 90% prolonged illness> 90% prolonged illness
Unique opportunities and risksUnique opportunities and risks
Little experience with deathLittle experience with death
Exaggerated sense of dying processExaggerated sense of dying process
Everyone will dieEveryone will die
< 10% suddenly< 10% suddenly
> 90% prolonged illness> 90% prolonged illness
Unique opportunities and risksUnique opportunities and risks
Little experience with deathLittle experience with death
Exaggerated sense of dying processExaggerated sense of dying process
Preparing for the last hours of life . . .Preparing for the last hours of life . . . Time course unpredictableTime course unpredictable
Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy
Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies
Regularly review the plan of care Regularly review the plan of care
Time course unpredictableTime course unpredictable
Any setting that permits privacy, Any setting that permits privacy, intimacyintimacy
Anticipate need for medications, Anticipate need for medications, equipment, suppliesequipment, supplies
Regularly review the plan of care Regularly review the plan of care
. . . Preparing for the last hours of life. . . Preparing for the last hours of life CaregiversCaregivers
Awareness of patient choicesAwareness of patient choices
Knowledgeable, skilled, confidentKnowledgeable, skilled, confident
Rapid responseRapid response
Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process
CaregiversCaregivers
Awareness of patient choicesAwareness of patient choices
Knowledgeable, skilled, confidentKnowledgeable, skilled, confident
Rapid responseRapid response
Likely events, signs, symptoms of Likely events, signs, symptoms of the dying processthe dying process
Physiological changes during the dying processPhysiological changes during the dying process Increasing weakness, fatigueIncreasing weakness, fatigue
Cutaneous ischemiaCutaneous ischemia
Decreasing appetite / fluid intakeDecreasing appetite / fluid intake
Cardiac, renal dysfunctionCardiac, renal dysfunction
Neurological dysfunctionNeurological dysfunction
PainPain
Loss of ability to close eyesLoss of ability to close eyes
Increasing weakness, fatigueIncreasing weakness, fatigue
Cutaneous ischemiaCutaneous ischemia
Decreasing appetite / fluid intakeDecreasing appetite / fluid intake
Cardiac, renal dysfunctionCardiac, renal dysfunction
Neurological dysfunctionNeurological dysfunction
PainPain
Loss of ability to close eyesLoss of ability to close eyes
Weakness / fatigueWeakness / fatigue
Decreased ability to moveDecreased ability to move
Joint position fatigueJoint position fatigue
Increased risk of pressure ulcersIncreased risk of pressure ulcers
Increased need for careIncreased need for care
Activities of daily livingActivities of daily living
Turning, movement, massageTurning, movement, massage
Decreased ability to moveDecreased ability to move
Joint position fatigueJoint position fatigue
Increased risk of pressure ulcersIncreased risk of pressure ulcers
Increased need for careIncreased need for care
Activities of daily livingActivities of daily living
Turning, movement, massageTurning, movement, massage
Decreasing appetite / food intakeDecreasing appetite / food intake Fears: ‘giving in’, starvationFears: ‘giving in’, starvation
RemindersReminders
Food may be nauseatingFood may be nauseating
Anorexia may be protectiveAnorexia may be protective
Risk of aspirationRisk of aspiration
Clenched teeth express desires, controlClenched teeth express desires, control
Help family find alternative ways to Help family find alternative ways to carecare
Fears: ‘giving in’, starvationFears: ‘giving in’, starvation
RemindersReminders
Food may be nauseatingFood may be nauseating
Anorexia may be protectiveAnorexia may be protective
Risk of aspirationRisk of aspiration
Clenched teeth express desires, controlClenched teeth express desires, control
Help family find alternative ways to Help family find alternative ways to carecare
Decreasing fluid intake . . .Decreasing fluid intake . . .
Oral rehydrating fluidsOral rehydrating fluids
Fears: dehydration, thirstFears: dehydration, thirst
Remind families, caregiversRemind families, caregivers
Dehydration does not cause distressDehydration does not cause distress
Dehydration may be protectiveDehydration may be protective
Oral rehydrating fluidsOral rehydrating fluids
Fears: dehydration, thirstFears: dehydration, thirst
Remind families, caregiversRemind families, caregivers
Dehydration does not cause distressDehydration does not cause distress
Dehydration may be protectiveDehydration may be protective
. . . Decreasing fluid intake. . . Decreasing fluid intake
Parenteral fluids may be harmfulParenteral fluids may be harmful
Fluid overload, breathlessness, cough, Fluid overload, breathlessness, cough, secretionssecretions
Mucosa / conjunctiva careMucosa / conjunctiva care
Parenteral fluids may be harmfulParenteral fluids may be harmful
Fluid overload, breathlessness, cough, Fluid overload, breathlessness, cough, secretionssecretions
Mucosa / conjunctiva careMucosa / conjunctiva care
Cardiac, renal dysfunctionCardiac, renal dysfunction
Tachycardia, hypotensionTachycardia, hypotension
Peripheral cooling, cyanosisPeripheral cooling, cyanosis
Mottling of skinMottling of skin
Diminished urine outputDiminished urine output
Parenteral fluids will not reverseParenteral fluids will not reverse
Tachycardia, hypotensionTachycardia, hypotension
Peripheral cooling, cyanosisPeripheral cooling, cyanosis
Mottling of skinMottling of skin
Diminished urine outputDiminished urine output
Parenteral fluids will not reverseParenteral fluids will not reverse
Neurological dysfunctionNeurological dysfunction
Decreasing level of consciousnessDecreasing level of consciousness
Communication with the Communication with the unconscious patientunconscious patient
Terminal deliriumTerminal delirium
Changes in respirationChanges in respiration
Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol
Decreasing level of consciousnessDecreasing level of consciousness
Communication with the Communication with the unconscious patientunconscious patient
Terminal deliriumTerminal delirium
Changes in respirationChanges in respiration
Loss of ability to swallow, sphincter Loss of ability to swallow, sphincter controlcontrol
Two roads to deathTwo roads to death
RestlessRestless
ConfusedConfused TremulousTremulous
HallucinationsHallucinations
Mumbling DeliriumMumbling Delirium
Myoclonic JerksMyoclonic JerksSleepySleepy
LethargicLethargic
ObtundedObtunded
SemicomatoseSemicomatose
ComatoseComatose
SeizuresSeizures
THE USUAL ROAD
THE USUAL ROAD
THE DIFFICULT ROAD
THE DIFFICULT ROAD
NormalNormal
DeadDead
Decreasing level of consciousnessDecreasing level of consciousness
‘‘The usual road to death’The usual road to death’
ProgressionProgression
Eyelash reflexEyelash reflex
‘‘The usual road to death’The usual road to death’
ProgressionProgression
Eyelash reflexEyelash reflex
Communication with the unconscious patient . . .Communication with the unconscious patient . . .
Distressing to familyDistressing to family
Awareness > ability to respondAwareness > ability to respond
Assume patient hears everythingAssume patient hears everything
Distressing to familyDistressing to family
Awareness > ability to respondAwareness > ability to respond
Assume patient hears everythingAssume patient hears everything
. . . Communication with the unconscious patient. . . Communication with the unconscious patient Create familiar environmentCreate familiar environment
Include in conversationsInclude in conversations
Assure of presence, safetyAssure of presence, safety
Give permission to dieGive permission to die
Touch Touch
Create familiar environmentCreate familiar environment
Include in conversationsInclude in conversations
Assure of presence, safetyAssure of presence, safety
Give permission to dieGive permission to die
Touch Touch
Terminal deliriumTerminal delirium
‘‘The difficult road to death’The difficult road to death’ Medical managementMedical management
BenzodiazepinesBenzodiazepinesLorazepam, midazolam Lorazepam, midazolam
NeurolepticsNeurolepticsHaloperidol, chlorpromazineHaloperidol, chlorpromazine
SeizuresSeizures Family needs support, educationFamily needs support, education
‘‘The difficult road to death’The difficult road to death’ Medical managementMedical management
BenzodiazepinesBenzodiazepinesLorazepam, midazolam Lorazepam, midazolam
NeurolepticsNeurolepticsHaloperidol, chlorpromazineHaloperidol, chlorpromazine
SeizuresSeizures Family needs support, educationFamily needs support, education
Changes in respiration . . .Changes in respiration . . . Altered breathing patternsAltered breathing patterns
Diminishing tidal volumeDiminishing tidal volume
ApneaApnea
Cheyne-Stokes respirationsCheyne-Stokes respirations
Accessory muscle useAccessory muscle use
Last reflex breathsLast reflex breaths
Altered breathing patternsAltered breathing patterns
Diminishing tidal volumeDiminishing tidal volume
ApneaApnea
Cheyne-Stokes respirationsCheyne-Stokes respirations
Accessory muscle useAccessory muscle use
Last reflex breathsLast reflex breaths
. . . Changes inrespiration. . . Changes inrespiration
FearsFears
SuffocationSuffocation
ManagementManagement
Family supportFamily support
Oxygen may prolong dying processOxygen may prolong dying process
BreathlessnessBreathlessness
FearsFears
SuffocationSuffocation
ManagementManagement
Family supportFamily support
Oxygen may prolong dying processOxygen may prolong dying process
BreathlessnessBreathlessness
Loss of ability to swallowLoss of ability to swallow
Loss of gag reflexLoss of gag reflex
Build-up of saliva, secretionsBuild-up of saliva, secretions
Scopolamine to dry secretionsScopolamine to dry secretions
Postural drainagePostural drainage
PositioningPositioning
SuctioningSuctioning
Loss of gag reflexLoss of gag reflex
Build-up of saliva, secretionsBuild-up of saliva, secretions
Scopolamine to dry secretionsScopolamine to dry secretions
Postural drainagePostural drainage
PositioningPositioning
SuctioningSuctioning
Loss of sphincter controlLoss of sphincter control
Incontinence of urine, stoolIncontinence of urine, stool
Family needs knowledge, supportFamily needs knowledge, support
Cleaning, skin careCleaning, skin care
Urinary cathetersUrinary catheters
Absorbent pads, surfacesAbsorbent pads, surfaces
Incontinence of urine, stoolIncontinence of urine, stool
Family needs knowledge, supportFamily needs knowledge, support
Cleaning, skin careCleaning, skin care
Urinary cathetersUrinary catheters
Absorbent pads, surfacesAbsorbent pads, surfaces
Pain in the last hours of life . . .Pain in the last hours of life . . . Fear of increased painFear of increased pain
Assessment of the unconscious Assessment of the unconscious patientpatient
Persistent vs. fleeting expressionPersistent vs. fleeting expression
Grimace or physiologic signsGrimace or physiologic signs
Incident vs. rest painIncident vs. rest pain
Distinction from terminal deliriumDistinction from terminal delirium
Fear of increased painFear of increased pain
Assessment of the unconscious Assessment of the unconscious patientpatient
Persistent vs. fleeting expressionPersistent vs. fleeting expression
Grimace or physiologic signsGrimace or physiologic signs
Incident vs. rest painIncident vs. rest pain
Distinction from terminal deliriumDistinction from terminal delirium
. . . Pain in the last hours of life. . . Pain in the last hours of life Management when no urine outputManagement when no urine output
Stop routine dosing, infusions of Stop routine dosing, infusions of morphinemorphine
Breakthrough dosing as needed (PRN)Breakthrough dosing as needed (PRN)
Least invasive route of administrationLeast invasive route of administration
Management when no urine outputManagement when no urine output
Stop routine dosing, infusions of Stop routine dosing, infusions of morphinemorphine
Breakthrough dosing as needed (PRN)Breakthrough dosing as needed (PRN)
Least invasive route of administrationLeast invasive route of administration
Loss of ability to close eyesLoss of ability to close eyes Loss of retro-orbital fat padLoss of retro-orbital fat pad
Insufficient eyelid lengthInsufficient eyelid length
Conjunctival exposureConjunctival exposure
Increased risk of dryness, painIncreased risk of dryness, pain
Maintain moistureMaintain moisture
Loss of retro-orbital fat padLoss of retro-orbital fat pad
Insufficient eyelid lengthInsufficient eyelid length
Conjunctival exposureConjunctival exposure
Increased risk of dryness, painIncreased risk of dryness, pain
Maintain moistureMaintain moisture
MedicationsMedications
Limit to essential medicationsLimit to essential medications
Choose less invasive route of Choose less invasive route of administrationadministration
Buccal mucosal or oral first, then Buccal mucosal or oral first, then consider rectalconsider rectal
Subcutaneous, intravenous rarelySubcutaneous, intravenous rarely
Intramuscular almost neverIntramuscular almost never
Limit to essential medicationsLimit to essential medications
Choose less invasive route of Choose less invasive route of administrationadministration
Buccal mucosal or oral first, then Buccal mucosal or oral first, then consider rectalconsider rectal
Subcutaneous, intravenous rarelySubcutaneous, intravenous rarely
Intramuscular almost neverIntramuscular almost never
Dying in institutionsDying in institutions
Home-like environmentHome-like environment
Permit privacy, intimacyPermit privacy, intimacy
Personal things, photosPersonal things, photos
Continuity of care plansContinuity of care plans
Avoid abrupt changes of settings Avoid abrupt changes of settings
Consider a specialized unitConsider a specialized unit
Home-like environmentHome-like environment
Permit privacy, intimacyPermit privacy, intimacy
Personal things, photosPersonal things, photos
Continuity of care plansContinuity of care plans
Avoid abrupt changes of settings Avoid abrupt changes of settings
Consider a specialized unitConsider a specialized unit
Signs that death has occurred . . .Signs that death has occurred . . . Absence of heartbeat, respirationsAbsence of heartbeat, respirations
Pupils fixedPupils fixed
Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles
Body temperature dropsBody temperature drops
Absence of heartbeat, respirationsAbsence of heartbeat, respirations
Pupils fixedPupils fixed
Color turns to a waxen pallor as Color turns to a waxen pallor as blood settlesblood settles
Body temperature dropsBody temperature drops
. . . Signs that death has occurred. . . Signs that death has occurred Muscles, sphincters relaxMuscles, sphincters relax
Release of stool, urineRelease of stool, urine
Eyes can remain openEyes can remain open
Jaw falls openJaw falls open
Body fluids may trickle internallyBody fluids may trickle internally
Muscles, sphincters relaxMuscles, sphincters relax
Release of stool, urineRelease of stool, urine
Eyes can remain openEyes can remain open
Jaw falls openJaw falls open
Body fluids may trickle internallyBody fluids may trickle internally
What to do when death occursWhat to do when death occurs Don’t call ‘911’Don’t call ‘911’
Whom to callWhom to call
No specific ‘rules’No specific ‘rules’
Rarely any need for coronerRarely any need for coroner
Organ donationOrgan donation
Traditions, rites, ritualsTraditions, rites, rituals
Don’t call ‘911’Don’t call ‘911’
Whom to callWhom to call
No specific ‘rules’No specific ‘rules’
Rarely any need for coronerRarely any need for coroner
Organ donationOrgan donation
Traditions, rites, ritualsTraditions, rites, rituals
Moving the bodyMoving the body
Prepare the bodyPrepare the body
Choice of funeral service providersChoice of funeral service providers
Wrapping, moving the bodyWrapping, moving the body
Family presenceFamily presence
Intolerance of closed body bagsIntolerance of closed body bags
Prepare the bodyPrepare the body
Choice of funeral service providersChoice of funeral service providers
Wrapping, moving the bodyWrapping, moving the body
Family presenceFamily presence
Intolerance of closed body bagsIntolerance of closed body bags
Pronouncing deathPronouncing death
““Please come…”Please come…”
Entering the roomEntering the room
PronouncingPronouncing
DocumentingDocumenting
““Please come…”Please come…”
Entering the roomEntering the room
PronouncingPronouncing
DocumentingDocumenting
Telephone notificationTelephone notification
Sometimes necessarySometimes necessary
Use 6 steps of good communicationUse 6 steps of good communication
Sometimes necessarySometimes necessary
Use 6 steps of good communicationUse 6 steps of good communication
Bereavement careBereavement care
Bereavement careBereavement care
Attendance at funeralAttendance at funeral
Follow-up to assess grief reactions, Follow-up to assess grief reactions, provide supportprovide support
Assistance with practical mattersAssistance with practical matters
Redeem insuranceRedeem insurance
Will, financial obligations, estate closureWill, financial obligations, estate closure
Bereavement careBereavement care
Attendance at funeralAttendance at funeral
Follow-up to assess grief reactions, Follow-up to assess grief reactions, provide supportprovide support
Assistance with practical mattersAssistance with practical matters
Redeem insuranceRedeem insurance
Will, financial obligations, estate closureWill, financial obligations, estate closure
EEPPEECC
OO
EEPPEECC
OO
SummarySummary
Care in last hours is as Care in last hours is as important as at any other time important as at any other time
in cancer carein cancer care
Care in last hours is as Care in last hours is as important as at any other time important as at any other time
in cancer carein cancer care
