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An introduction to the physiology and management of the dying process with emphasis on how to recognize patients who are dying. Geared toward physicians in the hospital setting.
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DIAGNOSING DYING: PHYSIOLOGY & MANAGEMENT FOR GENERALISTSKyle P. Edmonds, MDAssistant Clinical ProfessorDoris A. Howell Palliative Care ServiceUC San Diego Health System
Adapted from Palliative Care International Curriculum, Ed. Frank R. Ferris
OVERALL MESSAGE
Diagnosis and management of dying is an overlooked aspect of medical care.
The family’s perception of the process can have long-term consequences.
Dying is not inherently uncomfortable.
ANTICIPATORY GUIDANCE: LAST HOURS
Everyone will die < 10 % suddenly
Unique processes & risks
Little experience
ANTICIPATORY GUIDANCE: COMPLICATED BEREAVEMENT
Hx complicated bereavement Psych Hx / Dependent
personality Out of life-cycle norms Poor social support Absent frame of reference Sudden/violent death
MRS. A
84yo mother of two in the ED with cough/PNA
Accompanied by 62yo daughter PMHx: Alzheimer dementia,
distant Hx of curative lumpectomy for breast cancer, HTN, osteoarthritis
MRS. A (CON’T)
Presently: hypothermic, low white count, left shift; CXR with bibasilar atelectasis vs. consolidation
You admit her and start IV Abx What else do you need to
know?
DISCUSS MRS. A (~10 MINUTES)
PRINCIPLES OF MANAGEMENT
Diagnose Anticipatory guidance Environment Assessment Acknowledge Fears
Serious Illness
Dx: Dying
Ongoing Care Death
Care after death
Recovery
Adapted from : Ellershaw & Ward, 2003.
NORMALIZE THE ENVIRONMENT
Family presence Turn off monitors Minimize procedures Stop oxygen Include pt in conversations Touch
ASSESSMENT: COMFORTABLE?
PHYSIOLOGY OF DYING
Cardiovascular Renal Respiratory Gastrointestinal
HEENT Constitutional Neurological
VITAL SIGNS
Adapted from Fig 1: Bruera et al., 2014.
CONSTITUTIONAL
Terminal fever Pressure ulcer risk Symptoms: Weakness;
Fatigue; Joint position fatigue
FEVER
Fears: Suffering, Hastened death
Management Noninvasive cooling Rectal acetaminophen
CARDIOVASCULAR
Tachycardia, hypotension Peripheral cooling, cyanosis Third-spacing Mottling of skin… Symptoms: dizziness,
edema
MOTTLING
RENAL
Decreasing urine output Diminished GFR (changing
pharmacokinetics) Symptom: generally
comfortable
PAIN: CONTINUOUS OPIOIDS & OLIGURIA
<20ml/hr (500ml/d): decrease
<10ml/hr (250ml/d): stop! Always: bolus for symptoms
RESPIRATORY
Patterns: Tachypnea, Apnea Chin-lift, jaw-jerk*
Diminishing tidal volume Oropharyngeal secretions* Symptoms: generally
comfortable
CHANGES IN RESPIRATION
Fear: suffocation
Management Family support Oxygen variably effective Opioids
SECRETIONS
Fear: Choking, Drowning
Management Reassurance Positioning Glycopyrrolate
GASTROINTESTINAL
Loss of ability to swallow Dehydration Ileus Symptoms: anorexia;
nausea; dry mouth; incontinence
DECREASING FOOD INTAKE
Fear: Starvation
Management Normalize & Reframe Food for comfort Aspiration risk
PATIENT/FAMILY MEANING
“Food” = ?
PATIENT/FAMILY MEANING
No! “Food” =
DECREASING FLUID INTAKE
Fears: Thirst
Management Reassure Benefit/Burden of IVF Oral care
HEENT
Open eyes Loss of retro-orbital fat pad Insufficient eyelid length
Slack Mouth Symptoms: dry eyes; dry
mouth
XEROSTOMIA / XEROPHTHALMIA
Fears: Thirst, Suffering
Management Oral care Eye care
NEUROLOGICAL
Progressive decrease in LOC Preserved hearing & touch Delirium Pain not automatic! Symptoms: Confusion;
Drowsiness
PAIN
Fear: Uncontrolled pain
Grimace Physiologic signs Incident vs. rest pain Differentiation from delirium
RestlessConfused Tremulous
Hallucinations
Mumbling Delirium
Myoclonic JerksSleepy
Lethargic
ObtundedSemicomatose
Comatose
SeizuresUSUAL ROAD
DIFFICULT ROAD
Baseline
DeadNEUROLOGICAL: TWO ROADS TO DEATH
TERMINAL DELIRIUM
Fear: Terror
Management Diagnosis Consult me.
AFTER DEATH
Cardiopulmonary arrest Eyes often open Pupils fixed Jaw open Waxen pallor Muscles, sphincters relax
PRONOUNCING DEATH
“ Please come… ” Entering the room Pronouncing Documenting
OVERALL MESSAGE
Diagnosis and management of dying is an overlooked aspect of medical care.
The family’s perception of the process can have long-term consequences.
Dying is not inherently uncomfortable.
DIAGNOSING DYING: PHYSIOLOGY & MANAGEMENTKyle P. Edmonds, [email protected]: 619-471-9424P: 619-290-1212M: 928-853-1483
Adapted from Palliative Care International Curriculum, Ed. Frank R. Ferris
REFERENCES
Cozzolino, P, J., Staples, A, D., Meyers, L, S., & Samboceti, J. (2004). Greed, Death, and Values: From Terror Management to Transcendence Management Theory. Personality and Social Psychology Bulletin, 30, 278-292.
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Hughes AC, Wilcock A, Corcoran R. Management of “death rattle”. J Pain Symptom Manage. 12:271-272. PMID: 8942121. Full Text.
Sykes N, Thorns A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med. 2003;163(3):341-4. PMID: 12578515. Full Text.
Storey P. Symptom control in Dying. In: Principles and Practice of Supportive Oncology. Ed: A Berger, RK Portenoy, D Weissman. Lippincott-Raven Publishers, Philadelphia 1998;741-748. ISBN: 0397515596.
Twycross R, Lichter I. The terminal phase. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. Oxford, England: Oxford University Press; 1998:977-992. ISBN: 0192625667.
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