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Presented to HPM Fellowship July 2010. Has handout also uploaded.
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Care of the Imminently Dying Patient
July 8th, 2010
Christian Sinclair, MDKansas City Hospice & Palliative Care
Prognostication of the Terminal Phase
Working with Ranges - Minutes
Working with Ranges - Hours
Working with Ranges - Days
Death Trajectories
• Sudden Death
• Death from Acute Illness
• Death from Chronic Illness
• After Withdrawal of Life Support
Scales
• Palliative Performance Scale
• Palliative Prognostic Index
• Links available from:– prognosis.pallimed.org– EPERC Fast Facts
The Rally
What to Manage vs. What to Expect
What to Manage vs. What to Expect
Transforming from Patient-Centered Care to
Family-Centered Care
Time and logistics
Time and logistics
Time and logistics
Time and logistics
Time and logistics
Systems-Based Decline
Examination of the dying patient
Constitutional
Eyes & Oropharyngeal
Gastrointestinal
• Anorexia – Major family education point here – GI shut down – industrial analogy
• Cachexia – body image issues
• Decreased Fluid Intake – another major family education point
• Incontinence - dignity
Cardiovascular• Hypotension
– Hypovolemic– Cardiogenic– Septic
• Poor cap refill, cyanosis, mottling, edema
• Brady / Tachycardia– possible sign of distress body adjustment
• Implantable Devices– think ahead about deactivation
• Don’t forget about blood pressure meds
• Major prognostic value in imminent death
• Can be fooled with variation
Renal
Pulmonary
Skin Care
Neurological/Psychological
Considerations of Location
Spiritual/Existential Considerations
Medication Management
• Prognosis / Goal Mismatch– If not aligned then change the medications
• Pill Dysphagia- Think ahead for other options
• Alternate Routes– PR is not the only option– Topical medications – eh.
Unexplained Prolongation of the
Terminal PhaseNo one has really looked at this
population but it bears some examination.
For a copy of the slides, please email: [email protected]
• Recommended Reading/ Key References:
• Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3rd Ed.
• EPEC – Last Hours of Living, Module 12, 1999.
• Ferris FD, von Gunten CF, Emanuel LL. Competency in End-of-Life Care: Last Hours of Life. J of Pall Med. August 2003: 605-613.
• Plonk WM, Arnold RM. Terminal Care: The Last Weeks of Life. J of Pall Med 8(5): 1042-55