1. End of Life Symptom Management Dec 3, 2014 Mudit Dabral Rosene Pirrello

2. Understand concept of death Identify & manage common symptoms Objectives

3. Everyone will die <10% suddenly >90% prolonged illness Time course unpredictable Need to review the plan regularly Last Hours of Living

4. Affirms life Regards dying as a normal process Neither hastens nor postpones death Relieves symptoms Palliative Care

5. Integrates medical, psychological & spiritual aspects of care Is often a support system to patients & family Palliative Care

6. Anorexia (loss of appetite) Cachexia (Weight loss) Gradual Symptoms

7. Medications Depression Nausea Dysphagia Odynophagia Any advance disease Anorexia & Cachexia

8. Reversible causes – Medications side effects Pain Nausea Constipation Depression Anorexia & Cachexia

9. Lift dietary restrictions Environmental pleasantries Socialization Small portions Oral hygiene Anorexia - Cachexia

10. Metoclopramide Magesterol acetate Anorexia - Cachexia

11. ? Given up ? Not fighting Fatigue

12. Little is known about Pathophysiology & treatment Fatigue

13. Reversible Causes: Medications Dehydration Anemia Electrolyte imbalance Suboptimal sleep Fatigue

14. Give patient permission to rest Clarify the role of underlying disease Fatigue

15. Steroids Dexamethasone (2-20mg/d) Psychostimulants (methylphenadate 2.5-15 mg q AM & noon) Fatigue

16. Medications Decreased motility Impaction Mechanical obstruction Dehydration Metabolic (Hypercalcemia, Hypokalemia) Constipation

17. Treat the cause Laxatives - Stimulants, Osmotic Prokinetics Constipation

18. Nausea, vomiting Pain

19. Hospitalized patients: 14%-56% Dying patients 80%-90% Terminal Delirium

20. End of Life

21. Can contribute to complicated & prolonged grief disorder Diminishes opportunity for closure of relationships Terminal Delirium

22. Reversible 50% Pain Constipation Urinary retention Hypercalcemia, Hepatic failure, Hypoxia Infection Dehydration Medications Delirium

23. Major organ failure Hypoxic encephalopathy Terminal Delirium

24. Create a familiar environment Reassure family Give permission to die Touch Treatment - Terminal Delirium

25. Benzodiazepines - Lorazepam, Midazolam Neuroleptics - Haloperidol, Chlorpromazine Treat seizures Treatment - Terminal Delirium

26. Dyspnea Altered breathing patterns Low tidal volume, Cheyne-Stroke respirations Accessory muscle use Last few reflex respiratory efforts “Death rattle” Respiratory Changes

27. Fears – Suffocation Support family Oxygen may prolong dying process Purpose of treatment is relief of unpleasant sensation. Respiratory Changes

28. Opioids (MS2.5 -20mg) Steroids (prednisone 10-20mg 3x a day, Dexamethasone 8 mg per day) Anxiolytics (Lorazepam 0.5-2mg q 6 hrs) Diuretics Bronchodilators Anticholinergics (scopolamine patch, Glycopyrrulate 1 mg-2mg q 6-8hrs ) Dyspnea - Treatment

29. Care in the last hours is as important as at any other time in life Overall Message

30. QUESTIONS?