The Terminal Phase Rob Woodford ST1

The terminal phase: What is it? The period of inexorable and irreversible decline in functional status, prior to death May be gradual or more sudden Days/weeks Fluctuating or unfolding gradually May be after planned withdrawal of life sustaining intervention

What to look for Fatigue Loss of appetite Functional deterioration Communication Mobility Social engagement Progressive weight loss Decreased level of consciousness Mottled skin Changes in breathing Cheyne-Stokes breathing Noisy respiratory secretions

Main aims Two main aims of end of life care: Ensure best QOL for patient Supporting families and being mindful of long term effects.

Discussing treatment options No obligation to provide “futile” treatments But there is an obligation to communicate May know a good amount about potential treatments, but not why those options are not feasible. Plan before a crisis Discuss fears: Choking/suffocating/drowning Worsening pain Many people in these situations worry about … When you thing of the scary “What If” possibilities, what comes to mind? You might be wondering about...

Ceilings of care In case of deterioration – what would we do Where is the patient on their journey? Where do they think they are? Ask: Whether they would want hospital transfer Whether for CPR PPC and PPD If you became very unwell with a chest infection, would you want to go to hospital, if we thought it would help? Would you like us to do our best for you here, and aim for a peaceful death without medical interference?

Poor oral intake calorie intake Impaired swallow common Distinguish between Focal problem related to neuro illness/hypercalcaemia Part of profound generalised weakness in final days No compelling evidence that increasing calorie intake improves comfort or outcomes. Guide family to find other ways of supporting: basic care, just being present calorie intake There’s often no hunger or desire for food The body cannot properly use the food it takes in Strength Energy Functional status Survival

Poor fluid intake The body’s need for fluid reduces as they become weaker Inconclusive evidence around thirst/dehydration/excess secretions Dehydration may lead to impaired excretion and delirium Artificial hydration may prolong dying process, aggravate oedema, require drips… Hydration is likely to benefit in cases of Hypercalcaemia Reversible bowel obstruction In absence of clear harm, hydration may help family navigate “path of least regret” The deeply unconscious patient will not experience thirst

Poor fluid intake For Against Maintenance of patient comfort (e.g. prevention of thirst, prevention of dry mouth) Maintenance of renal perfusion Prevention of accumulation of toxins and drugs Prevention of delirium and opioid toxicity Peripheral oedema Cardiac failure Respiratory secretions Ketones and other byproducts of dehydration have analgesic and sedative effects

Management of pain NICE: SR morphine first line Decreased conscious level: Previous pain ongoing Family and healthcare team assess comfort Convert oral analgesia Continuous diamorphine (or morphine) infusion via a syringe driver PRN dose 1/6th driver dose Consider leaving patch in situ

Management of dyspnoea Non-pharmacological Elevate head of bed Fan for cool air Oxygen may relieve dyspnoea Pharmacological Opioids mainly Dose to comfort If anxiety present, use benzodiazepines/levomepromazine Oxygen – when to withdraw? No symptomatic benefit if unresponsive Lets wean down the oxygen and see if he remains settled…

Management of agitation Very common at end of life Distressing for family Many aetiologies In final hours, don’t look for cause… … But rule out hypoglycaemia and urinary retention. If longer prognosis, consider investigating further or trying other treatments Medication side-effect, brain tumour, infection

Management of agitation Levomepromazine PRN dose 6.25-12.5mg In driver 12.5-50mg/24hrs Haloperidol Not as sedating as levomepromazine From 0.5-3mg PRN In driver 5-15mg/24hrs Midazolam PRN dose 2.5-5mg In driver 10-100mg/24hrs Lorazepam PRN dose 0.5-1mg

Management of Nausea and vomiting Treatment based on cause Dysmotility Metoclopramide Biochemical Haloperidol Broad-acting levomepromazine

The death rattle High prevalence Patient not usually responsive Use an anticholinergic: Hyoscine butylbromide 20-40mg s/c Stat doses often work as well as infusion Repositioning Stop fluids

Risk of massive haemorrhage Prepare healthcare staff Education, clear plans Discussions with patient and family. If home death, will need clear open discussion, mostly with relative. Medications and equipment ready Needles/syringes, dark towels Aggressive use of sedatives for rapid comfort/unawareness E.g. midazolam 10mg IM/SC PRN IM better than SC route

Summary Recognition important Individualised approach Clinical needs Patient and family views Syringe-driver directive and anticipatory medications Ensure family knows what to do following an expected death: Call out of hours GP service to confirm the death Family then organise an undertaker to take the body Registered GP practice will normally complete the death certificate on the next working day

Guidelines http://wmpcg.co.uk/