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Recognising Dying in Older Person’s Care
August 2013
Definition of dying
• :ceasing to live, approaching death
• :of,pertaining to, or associated with death
• :drawing to a close, ending
• Actively dying - the last few days or hours of life
What is a Good Death?
• Respect patient’s wishes/autonomy
• Dignity
• Comfort
• Physical
• Emotional
• Spiritual
• Support of carers/family
– memory of dying process as positive as possible
• Cultural sensitivity
What is a Good Death
• Each death, like each life is unique
• Accompany not lead
• Advise not direct
• Death is not always neat and tidy!
• Best possible outcome, not ideal outcome
Community Palliative Care Team
• Up to mid August 2013 325 new patients seen
• 61 0f these non malignant diagnoses = 19%
• 81 % cancer diagnosis
About 30,000 people die in Ireland each year
While the majority of people would like to die at home-most people now die in a hospital, or similar setting, outside the home.
At least half of all deaths occur in acute hospitals(48%) or hospice (4%).Deaths at home(25%) : Community residential facilities/ nursing homes (20%)
(Irish Hospice Foundation)
Patients seen in nursing homes/community units
• 46 patients - 14%
• Cancer diagnosis - 16 pts (35%)
• Dementia- 18 (39%)
• Ischaemia/peripheral vascular disease – 4
• Pneumonia- 5
• Pain control – 1
• Neurological eg Parkinsons,MND - 2
Principal causes of death in Ireland 2010 (CSO)
Circulatory/Cardiovascular
35%
Other causes
24%
Cancer
29%
Respiratory
12%
Care of the dying
• Is about thinking of the obvious things and doing them well
• Recognising the point of no return
• Reassessing standard therapies
• Communication –patient, family, staff
• Symptom control
• (Dr S Higgins-Palliative Care in the last 24 hrs –doing simple things well.Cancerwise)
Why so important?
• Place of care
• Appropriate management
• Avoiding unnecessary interventions
• Communication with family
• Things to put right – reconciliations, sorries, thank yous
• Preparing eg young children
The point of no return
• Most difficult and most neglected step
• Doctors often the worst culprits!
• Can be a difficult call- even within hospice a ‘well’ patient may suddenly begin to die, whereas a ‘dying’ patient rallies
WHO
Lynn J, Adamson DM. Living well at the end of life: adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003
WHO
Lynn J, Adamson DM. Living well at the end of life: adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003
WHO
Lynn J, Adamson DM. Living well at the end of life: adapting health care to serious chronic illness in old age. Arlington, VA, Rand Health, 2003
Diagnosis of Dying?
• Increased weakness and immobility
• Drowsy/cognitive impairment
• Reduced oral intake and difficulty with oral meds
• Changes in breathing pattern
• Noisy/laboured breathing
• Changes in temperature regulation
• Circulatory changes • Cool peripheries/ pallor/ “marking”
• Very useful to document in notes- ‘’patient beginning to die’’- priority shifts to promoting a comfortable death rather than inappropriate interventions etc
Terminal Phase
• Day to day deterioration:
– strength, awareness, appetite
• If deterioration sudden then exclude a reversible cause:
• Infection
• Hypercalcaemia/ hypoglycaemia/ hyponatraemia
• Medication changes e.g. opioid/benzodiazepine
• Uraemia e.g. obstructive uropathy
Final Days of Life
• Good symptom control prolongs life
• Good end of life care/ communication with families has a major impact on bereavement
• Family may have questions? • Dying of disease or drugs?
• Can he hear me?
• Thirst?
• Starving to death?
• How long?
Symptom Control Issues
• Pain
• Dyspnoea / shortness of breath
• Nausea & vomiting
• Bronchial secretions
• Sudden events/ emergencies
• Mouth and pressure area care
Common symptoms
• Drowsiness & confusion 55%
• Moist respiration 45%
• Restlessness & agitation 43%
• Pain 26%
• Dyspnoea 25%
• Nausea & vomiting 14%
Aims in Terminal Phase
• To lessen distress for patient/family
• Analgesia still required
• Rationalize medications/ alternative route
• Titrate medications in line with symptoms
• Avoid unnecessary interventions
• Catheterisation
• Assess how carers/family are coping
• Open communication
Priority is comfort, comfort, comfort Management of symptoms and family support
are the priorities High level of stress for all Explore any fears, concerns, misconceptions Assurance of symptom control Discuss dying process, appropriate to needs Include children DNR, no transfer-documentation ‘‘Allow a natural
death ‘’
Care of Family
• Precious and stressful time
• Reawakens pain of previous losses
• Assess how carers are coping/reacting to changes
• Guilt
• Open and honest communication
• Coping in bereavement linked to experience around death
• Social support workers/ children
• Relatives with medical/nursing background!
Certainty/ Uncertainty
• Planning- work, family demand
• Relatives abroad
• Fatigue and exhaustion
• Wanting to be present at time of death
• Preparing children/grandchildren
Hours Before Death
• Advise family and suggest individual time with dying person
• Encourage to speak and touch, if appropriate
• Affirm individual’s role in caring process
• Religious rituals
• Offer appropriate explanation and reassurance
• Assure re pain free, comfortable etc.
• Share personal insight, anecdote, photograph etc.
• ‘Slowly I learn about the importance of powerlessness. I experience it in my own life and I live with it in my work.The secret is not to be afraid of it-not to run away.The dying know we are not God……..All they ask is that we do not desert them.’
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