The Last Days - the Essentials Dr Mary Kiely Consultant in Palliative Medicine CHfT

Important facts Presumption made that PPD is home Public’s lack of familiarity with dying Family’s preparedness Commitment from PHCT Forward planning and anticipatory care

Equipment 1 Hospital bed/profiling mattress Cantilever table Glideabout commode/catheter Recliner chair Baby alarm (Dark green towels)

Equipment 2 Extra pillows and bed linen Wet wipes Plastic box Fan Syringes/mouth care sponge sticks

Drugs - opioids Which drug/route, conversion ratios, daily dose AND prns Reduction in EGFR leads to reduction in opioid requirement Beware oxycodone availability

Drugs - opioids What to do with the fentanyl patch Zomorph to diamorphine OxyContin to oxycodone

Drugs - midazolam Anxiolytic at 10mg/24hrs Sedative at 20mg/24hrs Anti-convulsant at 30mg/24hrs Augments effect of opioids Renally excreted Maximum dose 80mg/24hrs

Drugs - haloperidol Anti-emetic (D2 antagonist) for chemical nausea - uraemia, hypercalcaemia, cytokines, etc Doubles as anti-psychotic Dose range mg/24hrs Accumulates in liver failure

Drugs - Buscopan Anti-secretory and anti-spasmodic Doesn’t cross blood-brain-barrier Maximum dose 120mg/24hrs for death rattle; 300mg/24hrs for colic Incompatible with cyclizine

Other drugs Ketorolac Alfentanil Levomepromazine Octreotide Remember water for injection (saline for ketorolac)

Preparedness Palliative Care Handover form to NHSD Region-wide DNACPR form Your willingness to reassess and revisit Requirements for death certification Wishes re corneal donation

Stuff to tell the family Explain the DNACPR form Explain OOHs’ services Dying can take time/role of self care Physiological changes Explicit discussion about lack of food/fluids What to do when the patient dies

Remember! Vital role of district nurses Joint assessments with CNS Out of hours’ advice from Consultants and SPC staff 24/7 Look after yourself