1. Preparing for the Predictable Planning for common threats to comfort in the final days. Tamara Wells RN MN CNS Dr. M. Harlos Medical Director WRHA Palliative Care Program

2. Disclosures No conflicts of interest Many thanks to all the members of my team and others for their insights and help with this presentation.

3. Objectives To review some of the common predictable symptom scenarios at end of life To review both pharmacologic and non- pharmacologic symptom management strategies To discuss how end of life care is a team effort

4. Death in the PCH Residents live ~2.2 yrs post-admission - 82% died in the PCH - Diagnoses (Approx. 3 co-morbidities/death certificate) Cardiovascular67% Dementia41% Infectious diseases30% Cerebrovascular24% Metabolic17% Cancer10% (K Klassen, S Wowchuk. WRHA chart audit, 2002)

5. Illness Trajectories Field & Cassel, 1997 Sudden Death Steady Decline/Expected Death Steady Decline with Crises

6. Functional decline transfers, toileting, eating Difficulty swallowing medications Fatigue and decreased activity tolerance Increased presentation of symptoms Concerns of family and friends Common Signs

7. Who is the team? Family Nurses/ Health Care Aides Recreation/ Housekeeping Allied Health Partners Patient

8. 1.Shortness of Breath 2.Confusion/Delirium 3.Pain 4.Loss of Appetite & Dehydration 5.Constipation 6.Nausea & Vomiting 7.Secretions Common Symptoms

9. LTC End of Life Pathways

10. Resident describes air hunger/breathlessness Or Resident unable to describe dyspnea but exhibits evidence of respiratory distress: Increased work of breathing Increased respiratory rate Using accessory muscles Agitated, restless, fearfulness Dyspnea - Assessment

11. Non-Pharmacological Management Position sitting upright Cool air (fan or open window) Oxygen for alert resident (& hypoxic) Pace or minimize activity Light bed covers, loose clothing Good mouth care Quiet music, calm presence, distraction

12. Pharmacological Management MedicationIndicationsRouteStarting Dose Frequency Morphine Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual2.5-5mgq4h + q1h prn Subcut1.25- 2.5mg q4h + q1h prn hydroMorphone (Dilaudid ®) Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual0.5-1mgq4h + q1h prn Subcut0.25- 0.5mg q4h + q1h prn

13. Acute onset of global cognitive impairment related to general medical condition with: Fluctuating consciousness Disorientation Disrupted sleep-wake cycle Reduced attention Perceptual disturbances Disorganized thinking Paranoid ideation Delirium - Assessment

14. The Confusion Assessment Method (CAM) 1. Acute onset 2. Inattention 3. Disorganized Thinking 4. Altered Level of Consciousness 5. Disorientation 6. Memory Impairment 7. Perceptual Disturbances 8. Psychomotor Agitation and Retardation 9. Sleep/Wake Cycle Disturbance 1 and 2 + 3 or 4

15. Delirium - Assessment If clinically appropriate & consistent with goals of care- assess & treat potentially reversible causes of delirium such as : Infections Adverse medication effects Metabolic abnormalities Pain Urinary retention Hypoxia

16. Is the resident agitated, restless or demonstrating responsive behaviours? NO Hypoactive Delirium Sedation not indicated Provide general comfort measures Support family Management

17. Is the resident agitated, restless or demonstrating responsive behaviours? Management YES=Hyperactive Delirium Non-pharmacological Keep a calm and reassuring presence Decrease environmental stimuli Pace or modify activity Monitor other factors that can impact comfort (constipation, urinary retention) Communicate with the team and family Encourage sips of fluid

18. MedicationIndicationsRouteStarting DoseFrequency Haloperidol (Haldol ® ) Agitated delirium – Pathway A Oral or sublingual 0.5-1 mg q6-8h prn + q1h prn Subcut0.5-1 mg q6-8h prn + q1h prn Methotrimeprazine (Nozinan®) Agitated Delirium Pathway A Nausea and Vomiting Pathway D Oral/subling /subcut 5mgq6-8h + q1h prn 5-25mg for severe agitation q6-8h + q1hprn Pharmacological Management

19. Delirium Monitoring Reassess every 24 hours or sooner depending upon response Consider increasing dosages dependent upon starting dose Consider stopping Haldol and moving to methotrimeprazine if delirium non-responsive to initial therapies

20. Noisy secretions present AND distressing to resident and/or family 1 st : Try repositioning. “Best side” Oral suction? Only if visible oral or posterior pharyngeal secretions No deep suctioning Noisy Secretions Non-pharmacologic treatment

21. Pharmacological Management Is the Resident alert? Glycopyrrolate 0.2-0.4mg subcut q2h PRN If secretions persist: consider using a scheduled dose of glycopyrrolate 0.2- 0.4mg subcut q6h & q1h PRN Scopolamine 0.3-0.6mg subcut q1h PRN If secretions persist: consider using a scheduled dose of scopolamine 0.3- 0.6mg subcut q4h & q1h PRN YES NO

22. Pharmacological Management MedicationIndicationRoute Starting Dose Frequency Glycopyrrolate Noisy secretions - Pathway C Subcut0.2-0.4 mg q2hprn If secretions persist, q6h + q1h prn Scopolamine Noisy secretions - Pathway C Subcut0.3-0.6 mg q1hprn If secretions persist, q4h + q1h prn

23. Noisy Secretions - Monitoring Review secretions management every shift – Effective: Continue present treatment If receiving scheduled doses of glycopyrrolate or scopolamine, consider switching to prn only – Ineffective: Maximize doses and schedule of antisecretory medications Reevaluate positioning of the Resident Support the family

24. Pain Pain may be related to medical complications Pain may be related to chronic conditions If pain exists it should be treated until end of life Dying of itself is not painful

25. Pain Assessment Ask the patient (verbal indicators) Observe the patient (non-verbal indicators) Talk to family Investigate the medical history Present pain medications Standardized reporting PQRST – Provoking factors, Quality of pain, Relieving factors, Severity and Timing

26. Assessment Tools

28. Pain Assessment and Management Patient already on Opioids If prn only consider scheduled Change long-acting to short acting equivalents Use q4h dosing for already scheduled short acting Increase opioid factor by 20-100% dependent upon context Monitor for best route Patient not on Opioids Start with the lowest dose Start with the longest interval Monitor regularly Use breakthrough opioid when indicated

29. Pain-Pharmacologic Management MedicationIndicationsRouteStarting DoseFrequency Morphine Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual2.5-5mgq4h + q1h prn Subcut1.25-2.5mgq4h + q1h prn hydroMorphone (Dilaudid®) Dyspnea (Pathway B) Pain (Pathway D) Oral/sublingual0.5-1mgq4h + q1h prn Subcut0.25-0.5mgq4h + q1h prn

30. Pain-Nonpharmacologic Management Pace and prepare for activity Use distraction and diversion Communicate between team members Decrease environmental stimuli Provide for spiritual/psychosocial support Reassure the patient/family Manage hydration when able

31. Assessment Review every 24 hours Pain not controlled if >3/24 hours Pain controlled alert and less than <3 breakthrough doses/24hrs Monitor for over sedation – If not using breakthrough but sedated consider dose reduction of 20-50%

32. Sedation vs. Euthanasia Dr. M. Harlos 03/12/14

33. When Death is Near Declining energy and alertness Decreasing intake of food and fluids Difficulty swallowing Mottling of the extremities Changes in breathing pattern Decreased urine output Return to basic reflexes

34. When should you ask for help? Symptom control not being achieved Disagreement between team members Feeling uncertain about the steps you are taking Goals of care have been unclear Help with conversion of medication other

35. Who can you call? WRHA Palliative Care Program – 204-237-2400 – A Clinical Nurse Specialist or Physician will be able to assist

36. Questions/Comments

37. Resources 1.Long Term Care Website: http://home.wrha.mb.ca/prog/pch/EndofLifeCareEducationHandouts.php 2.Canadian Virtual Hospice: http://www.virtualhospice.cahttp://www.virtualhospice.ca 3.WRHA Palliative Program: 204-237-2400 4.Hospice and Palliative Care Manitoba for volunteer visiting and grief support Phone: 204-889-5825