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Priority 5 - Plan & Do.
Individual plan of care delivered with compassion
Jacquie UptonHospice at Home Lead
Early opportunity to discuss, record and update patients wishes and preferences as apart of individualised care planning
Extent of dying persons, their families/carers wishes for involvement
Views, beliefs and values respectedRemember a person is deemed to have
capacity unless proven otherwiseIndividual plan of care “agreed,
communicated, adhered to and regularly reviewed” by all involved
Planning Care
Undertake a holistic assessment for end of life needs and preferences in partnership with the patient, family/carers.
Integrated approach with other health and social care professionals involved
Assessment
Physical needs Emotional Social Psychological Spiritual needs Cultural and religious
Assess and respond sensitively to:
Assessment never stops!Subtle changes are significant and importantNeed to listen to family and carers they know
their loved oneCommunicate, share, record and document
changes and actions taken with clear rationale so all involved have an understanding
Explanation to patient and family crucial
Continual Assessment
Assessing
There will come a point when a patient will not safely be able to eat or drink.
Informed choice - The patient may continue to try eating and drinking and risk aspiration, choking if they have capacity this needs to be respected
Family and friends understanding benefits and burdens around dehydration at the end stages of life
General Medical Council 2010 guidance – Treatment and care towards the end of life: good practice in decision making and relevant clinical guidelines.
Food and Drink
Southern Health and Solent NHS have medicines administration orders for Syringe drivers and PRN medication
These are supposed to be universal across the areas to minimise drug administration error
A clear rationale needs to be assessed and recorded prior to administration
Honouring of DNACPR by professionals Referring to SPCT as needed
Symptom Control
Anticipatory –foresee, act in advance ofGenerally -only drugs needed are:
Analgesics for pain Anti-emetics for nausea & vomiting Anti-cholinergics for resp secretions or
‘death rattle’ Sedatives/anti-convulsants for
agitation
Explain to patient and family Important Conversations
Anticipatory medications at End of Life
Patient unable to take oral medication and has been symptomatic Nausea and vomiting Unable to swallow Weakness Confusion Coma
Poor alimentary absorption Medication more effective given by alt. route Bowel obstruction
Indications for a syringe driver:
IMPORTANT !!!!!!
Medications need to be regularly reviewed and adjusted to give optimum effect and alleviate risk of toxicity.
Is a subjective and abnormal feeling or sensation which the patient experiences.
Is a feeling of something being 'not quite right' about one's body and is usually uncomfortable or, at least, unwanted.
May occur suddenly or be present for a while. May occur intermittently or may become
progressively worse. A patient may experience several symptoms at
the same time. The symptom (including its severity) is
something that only the patient can truly know
A Symptom
Several symptoms may be inter-related and by treating one you may well relieve others
A patient may be in such pain that he or she is unable to move around, and needs to take regular codeine for pain relief.
Constipation (if a laxative is not taken at the same time.)
The patient’s pain allowing them to move around more freely, thus improving their bowel movements
Underlying Symptoms
Pain (often several types simultaneously)
BreathlessnessNausea/vomitingRespiratory secretionsNoisy breathingPressure area damageConfusionAgitation/restlessnessElimination problems-Urinary
incontinence/retentionDry/sore mouthFatigue
Most commonly reported symptoms…
Unrelieved pain causes unnecessary harm and suffering
Pain diminishes activity, appetite, sleep and quality of life
Pain further debilitates already weakened patients Full pain assessment/ using a pain tool validates
the patients pain, helps patient to describe pain more accurately, increases the reporting
Provides understanding of the personal experience of
pain and the impact that pain Measuring severity of pain helps to understand the
effectiveness of our intervention
Importance of accurate assessment
How would you assess or recognise a persons pain?
Assessment of Pain
TOTAL PAIN
Source: Twycross & Wilcock (2001)
Spiritual:• Why has this happened to me?• Why has God allowed this?• What’s the point of it all?• Is there any meaning or purpose to
this?• Can I be forgiven for past
wrongdoing?
Social:• Worry about
family• Job + prestige
loss• Loss of social
status• Family role loss• Isolation• Abandonment
Physical:• Other symptoms• Adverse effects of
treatment• Insomnia and chronic
fatiguePsychological:• Anger at delay in
diagnosis• Anger at
therapeutic failure
• Disfigurement• Fears of pain• Fears of
helplessness
• Sore mouth• Earache• Difficulty in
going to the toilet
• Painful joints• Painful sores• Uncut fingers
or toes• Being in same
position for a long time
• Being moved uncomfortably
• Where are my family
• Where are my friends
• Loss of independence
• Loss of confidence
• Loss of social networks
• Loss of role or job
• How do I belong here?
• Loss of abilities in relation to activities I love
• Why me?
• Loss of home• Loss of
confidence• Loss of self
esteem• Loss of loved
ones• Anger and
frustration
Physical Social
SpiritualEmotional
There are a variety of pain assessment tools to choose from. Here are a fewVisual Analogue Scale: patient is asked to
mark a point on the line to represent the intensity of the pain from none to worst pain
Numerical Rating Scale: patient is asked to score the pain from 0 to 10 where 0 represents no pain and 10 represents worst pain
Descriptive Words Scale: a patient is asked to use a list of adjectives to describe pain intensity ranging from none to worst
Pain Tools
The Pain Assessment in Advanced Dementia (PAINAD)
Dolopus 2 A Faces Rating Scale Abbey pain tool Disdat
Pain Tools
PPQRST Pain Assessment Tool-Factors…. So ask… So consider…
P Palliative What makes it better? What improves it?
Heat pads, distraction etc.
P Provokes What makes it worse?
Movement, deep breathing.
Q Quality What is it like? Be descriptive
Sharp, stabbing, dull, ache.
R Radiation Does it spread? Where?
Referred pain.
S Severity How bad is it? How does it affect your life?
T Timing Is there a pattern, time the pain comes on? What makes it worse
Can we change an activity to help?
Pain Assessment Tools
Pain assessment tools
Example
Good pain management requires the patient to give a good history of their pain
Try to optimise the patient’s own ability to report and describe pain
Take collateral histories from carers if necessary
Summary of pain assessment
Things that lower the pain threshold
InsomniaFatigueAnxietyFearAngerBoredom
SadnessDepressionSocial isolationSocial
abandonment
Pain-
Not all patients will experience pain, so be mindful of creating an
expectation!
The WHO Analgesic Ladder
Usually start with immediate release
morphine Every 4 hours, 2.5mg -10mg,
with the prn equal to the 4hrly dose
If using modified release morphine,
give 10mg-30mgbd, depending on
previous weak opioid,
Starting Opioids – To gain control of the pain
Start low and titrate upRegular dose of IR (immediate
release) preparation and PRN (1/6th of total)
Prescribe a laxative – opioids nearly always cause constipation!
Watch for nausea/vomiting (usually wears off after a few days)drowsiness, confusion/hallucinations
General Principles of using Strong Opioids
Strong OpioidsImmediate Release Modified Release
Morphine Liquid (Oramorph)Tablet (Sevredol)Injection (Morphine Sulphate)
Usually capsules but some preparations are tablets
Diamorphine Injection None available
Oxycodone Liquid (Oxynorm)Capsule (Oxynorm)Injection (Oxynorm)
Tablets (Oxycontin)
Fentanyl InjectionLozenges (Actiq)Buccal and sublingual preps
Patch – dose expressed in mcg/hr, changed every 72 hours
Buprenorphine Sub lingual tablets Patch – dose expressed as mcg/hr, some patches changed every 72 hours, others every week
Methadone Liquid, tablets, Injection. Due to different pharmacokinetic properties, as stored in fat cells, no immediate release preparation
Oral morphine to sc morphine
Calculate daily dose of oral morphine
Divide total oral dose by 2Sub cut morphine is 2x as strong as oral morphine
This is the equivalent daily (24hr) dose of morphine
Insufficient analgesia Cognitive impairmentSedationNauseaConstipation – fentanyl and buprenorphine are
less constipatingRenal impairment – morphine is excreted by the
kidneys, so may accumulate in renal failurePruritusMyoclonus
Reasons for Switching Opioids
Respiratory depression almost never a problem in cancer pain if
used sensiblyAddiction almost never a problem in cancer painOnly for the terminal phase definitely has a role for severe pain at any
stage in the disease trajectoryHastens death – NOT if used appropriately and
sensibly
Myths about Morphine
signs of toxicity
DrowsinessConfusionPin point pupilsMyoclonic jerksNausea/vomitingHallucinations (auditory/visual)Respiratory depression
Complementary therapiesAcupunctureTouch/massageReflexologyAromatherapyArt therapy/music therapyPsychological supportReassuranceGood communicationSpiritual counselling
Other Approaches
Think about a time when you have witnessed someone struggling with a symptom.
What happened?
Case Scenario
What symptoms or factors can cause agitation?
Agitation
Look for reversible cause and treat if appropriate Pain Urinary retention Drugs Infection Constipation Haemorrhage Anxiety Terminal agitation
Agitation
Multi-professional approach if terminal agitation need to work together as a team to manage this affectively
Assess the patient rule out what factors are exacerbating the agitation i.e. place a catheter in for retention
Listen to patients and relatives is there an opportunity to discuss anger, fear or guilt issues. Can the chaplain or their own religious leader facilitate?
Drug therapy assess which medication would be beneficial for their agitation. Rule out other symptoms such as pain or breathlessness first.
Management of Terminal Agitation
Midazolam a short acting benzodiazepine which helps to reduce anxiety and aggression, relaxes muscles, suppresses seizures and sedates.
Levomepromazine an antipsychotic which has a longer action for sedation in terminal agitation. It can act as an anti-emetic
Haloperidol an antipsychotic for agitated delirium. Also acts as a anti-emetic
What medications help with terminal agitation/restlessness?
Aromatherapy: there are certain essential oils which can aid grief and distress for both patient and family
Soothing music: enquire from patient or relatives what kind of music they like
Environment: is the room too hot or cold?
Spiritual care: does the Chaplain or Vicar need to come in to perform a religious intervention or does a figure head from another religion need consulting? “Unfinished business”
Reassurance: touch, voice, calmness, need to talk
Non-Pharmaceutical Interventions
Identify the cause of nausea and vomiting Treat the cause if possible and appropriate Target the antiemetic to the specific cause Use the oral route if mild nausea Use the subcutaneous route with severe
nausea, or if vomiting
Nausea & Vomiting - Key points on management
Haloperidol as an anti emetic (Also acts as a antipsychotic for agitated delirium) May cause jerking
Review dosage after 24hours. If two or more PRN doses given, then consider syringe driver
Levomepromazine as an anti emetic (Also acts as a antipsychotic) May cause hypotension, drowsiness, dry mouth and other anticholinergic effects
Cyclizine antihistamine with anticholinergic action (Avoid in heart failure) Can irritate the skin needs to be mixed with WATER and not Saline
What medications help with Nausea & Vomiting (EOL)
Mouth – coated tongue, candida etc Environment – sights, smells, bad
tastes, tablet burden Anxiety - ?use of lorazepam esp. if
anticipatory N&V Memory, fears
Don’t forget…
Try repositioning patient Stop infusion or NG feed Anticholinergics can reduce volume of secretions if
given in time Hyoscine Butylbromide 20mg – 120mg via syringe driver
over 24 hrs, 20mgs upwards PRN Hyoscine Hydrobromide (sedation effect) 400mcg –
2.4mg via syringe driver over 24 hrs, 400mcg sc prn Breathlessness 1.0 -2.5mg of immediate release oral
morphine 4 hourly prn & titrate upwards
Explain to family – Be clear about what the “noise is”
Breathing - Secretions ‘Death rattle’
Environment–room temp, ventilation, reassurance Consider whether patient is already taking oral
morphine for breathlessness If the patient is not already taking morphine ensure
prn morphine Sulphate 5-10mgs or diamorphine 2.5 - 5mgs prn is prescribed
If patient is already taking morphine ensure appropriate prn dose sc morphine prescribed
Convert to syringe driver with appropriate dose morphine/diamorphine
Lorazepam 0.5-1mg S/L(quick acting) for acute crisis and panic attacks
Medications to consider with sensation of Breathlessness (EOL)
Potential symptoms are multiple Assess and ensure PRN meds available Identify and plan care Rule out reversible causes Include spiritual & social assessment Evaluate effect of any interventions Communicate plan with Next of Kin Always document and record rationale
Summary : Symptoms at End of Life
Thank you