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A challenging weekend--. Sunitha Daniel ST3. Case1. KM, 50 years Admitted to hospice on 22/10/11 Diagnosis locally advanced uterine leiomyosarcoma with lung metastasis Diagnosed in Aug 2010 6 cycles of neoadjuvant chemo(Ifosfamide + Doxorubicin) - PowerPoint PPT Presentation
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A challenging weekend--Sunitha Daniel
ST3
Case1 KM, 50 years
Admitted to hospice on 22/10/11
Diagnosis locally advanced uterine leiomyosarcoma with lung metastasis
Diagnosed in Aug 2010
6 cycles of neoadjuvant chemo(Ifosfamide+ Doxorubicin)
Initial response-decrease in size of tumor and lung mets
TAH with BSO in April 2011 –clear margins
Stable lung disease being considered for resection but progressed with abdominal lymph nodes
Palliative chemo 1st cycle on 06/10/11
Admitted to SJUH on 11/10/11 with chest pain and SOB
CT scan showed progressive lung disease, pleural effusion and pelvic disease.
Treated with IV antibiotics for neutropenic sepsis
Rapid deterioration in breathing
Referred for management of breathlessness and likely terminal care.
Past History
PE
Fibroid Uterus
2 Hickman line infections
Social history Used to work as a clerical staff in fire station (health and safety)
Lives with husband and 2 sons aged 23 and 11.
Family –not coping especially eldest son.
Symptoms Pain 3/3 severe upper back pain radiating to front of chest ongoing for
weeks. Relieved on sitting up, lying to right side. opioid sensitive
Dyspnoea 3/3 on minimal exertion as well as talking. Stopping mid conversation. There was evidence of anxiety
Drowsiness 3/3 Noticed only after CSCI started. Dozing of during conversation.
Examination Generally looked anxious and tachypnoic
pallor+
Obs HR 112/mt,RR 28/mt SO2 93% on O2
Chest bibasal creps more on left.
Mouth: evidence of oral thrush
Management From SJUH On CSCI Morphine 90mg +Midazolam 10mg
Dexamethasone 8mg by Oncologist
Diclofenac TDS
At hospice Discussion with family Aware of progressive disease but told by oncologist
about possible chemo if chest improves.
Concerns regarding drowsiness
Patient be rather be more awake.
Continue CSCI with Morphine and but Midazolam 7.5 mg
Reduce Dexamethasone to 4mg.
Progress (23/10/11) Very agitated night –shouting screaming and moving around
Ongoing pain
PRN Morphine, midazolam and haloperidol overnight
Reviewed: gave stat haloperidol and changed driver to Morphine 100mg and midazolam 20mg.
Worsened during day : worsening hypoxia. ? Dying
D/W consultant Agreed could be dying. To speak with husband but not to speak /involve son (suicidal risk)
Husband visibly upset and shocked –called in family including son
Consultant review
lengthy discussion : patient accepting but not talking about it.
Family agreed for more sedation
Changed CSCI To Oxycodone 50mg and midaz 30mg
Commence LCP (18:00)
Family stayed in .
Called at 00:50 patient still unsettled PRNs 5 in 5 hours
Family upset
Reviewed stat levomepromazine and changed to Oxy 80mg,Midaz 60mg and Levo 12.5mg in CSCI at 3:00am
24/10/11 Few more PRNs
Review by Consultant(8am)
Unconscious but not settled moaning with each breath
Family present throughout night
Phenobarbitone 100mg at 9:00am -finally relaxed
RIP at 11:50 am
Case 2 EB 77 years male
Back ground End stage heart failure sec to IHD
Admitted on 21/10/11
Worsening Oedema, pain drowsy
Admitted for terminal care
Aware he is dying-‘Please put me to sleep’
On high dose opiates orally pain uncontrolled but S/C PRN worked.
Symptoms
Pain(3/3) across the chest and back ? Related to heart failure.
Nausea(3/3)
Peripheral oedema(3/3)
Examination Restless and agitated
SO2 90% BP 99/69
Raised JVP
Chest Bibasal fine creps and dull to percussion
Abdomen Ascites+
Management CSCI with Morphine25mg Midazolam 10mg Haloeperidol 3mg
Frusemide CSCI 160mg
Stop non essential meds.
Progress(22/10/11 -23/10/11) Unsettled night with worsening pain and agitation
Not clear as to cause of agitation? dying
CSCI changed to morph 40mg,midaz 20mg and halo 5mg
Continued to be more agitated all day and night( up all night needing extra nursing care)
D/W Consultant morphine 60mg,midaz 40mg with PRN 5-10mg for Levo PRN, ketorolac BD
Not clear if terminal
24/10/11 Still very restless.
Getting up to pass urine at night - catheterize
Still having meals with family during day –agitation and restlessness predominantly at night.
CSCI to Morphine 100mg,midaz 75mg and haloperidol1.5mg(?rigid)
Not clear if dying D/W family-
D/W consultant(16:00)
Stop Frusemide,Switch to Oxycodone,for midaz 30mg in day and 60mg at night,Stop haloperidol Ketorolac CSCI
Not for LCP as not clear if dying
CSCI started at 18:00
Settled later in night.
RIP during cares at 02:45 am on 25/10/11
Good death (BMJ 2000;320:129) To know when death is coming,
To understand what can be expected
To be able to retain control of what happens
To be afforded dignity and privacy
To have control over pain relief and other symptom control
To have choice and control over where death occurs.
To have access to information and expertise of whatever kind is necessary
To have access to any spiritual or emotional support
To have access to hospice care in any location, not only in hospital
To have control over who is present and who shares the end
To be able to issue advance directives which ensure wishes are respected
To have time to say goodbye, and control over other aspects of timing
To be able to leave when it is time to go, and not to have life prolonged pointlessly
Factors considered important at the end of life by patients pain and symptom management,
communication with one's physician,
preparation for death.
opportunity to achieve a sense of completion
Ref(JAMA 2000; 284(19): 2476-82)
Diagnosing dyingProfound weakness
Confined to bed for most of the day
Drowsy for extended periods
Disorientated
Severely limited attention span
Loss of interest in food and drink
Too weak to swallow medication.
Why is it Important? Allows withdrawal of unnecessary treatments
Preparation of the patient and family/carers for death.
Establish patient’s PPOC.
NICE Quality Standard for End of Life Care for Adults. 16 steps for people approaching end of life care
Identification in timely way
Communication and information provided to patients and families.
comprehensive holistic assessments in response to their changing needs and preferences,
physical and specific psychological needs safely, effectively and appropriately met
offered timely personalised support for their social, practical and emotional needs,
offered spiritual and religious support
Families and carers of people approaching the end of life are offered comprehensive holistic assessments.
receive consistent care that is coordinated effectively across all relevant settings
who experience a crisis at any time of day or night receive prompt, safe and effective urgent care.
who may benefit from specialist palliative care, are offered this care in a timely way appropriate to their needs and preferences,
last days of life are identified in a timely way and have their care coordinated and delivered in accordance with their personalised care plan,
Care after death, bereavement support and work force planning and training.
“…we will do all we can not only to help you die peacefully, but to live until you die.”
Dame Cicely Saunders
References YCN symptom management
NICE
BMJ