1. 5 mins on last days of life and palliative care emergencies ! Dr. Ros Taylor Hospice Director Hospice of St. Francis Berkhamsted June 2012

2. Know who to ring !!! Know where the resources are ! Mount Vernon Cancer Network Advice 01923 844281 Hospices….open all hours Peri-patetic Marie Curie Nurse OOH District Nurses

3. Last moments of life Precious Very symbolic to be together Hours at bedside - focus on separation and memories

5. Acknowledge death is near Fundamental to good management  Allows symptom control and decisions  Allows final business and acceptance If ignore closeness to death  No care of dying  Inappropriate treatment

6. Surprise Question “ would I be surprised if this patient died in ………..a few days ??”

7. Anticipate We can see the future…..often

8. Clinical intuition Declining mobility Distracted and distant Breathless Difficulty swallowing Circulation changes PEOPLE KNOW !!

9. Limit treatment to : Analgesia s/c diamorphine or morphine Sedation if needed s/c midazolam or levomepromazine Anticholinergic s/c glycopyrronium or hyoscine

10. Just in Case Boxes 3-5 days of –Analgesia –Sedation –Drying agent –Anti-nausea

11. Stopping medication Stop futile medication - treat symptoms only If unable to swallow - use parenteral route

12. Syringe drivers When to use  Unable to take oral medication  Nausea and vomiting  Dysphagia  Unconscious What to use

13. Fentanyl in the last days Keep patch on at same dose death Add extra analgesia as morphine in a driver

14. The Pain of it all

15. Managing terminal pain Continue analgesia until death If not swallowing then s/c infusion of diamorphine with 1/3 of previous oral morphine dose Breakthrough pain  Use sixth of 24hr opioid dose If not had opioids  Then 10 - 20mg diamorphine s/c per 24 hrs  Plus anti-emetic

16. Terminal Dyspnoea INSPIRE EXPIRE Powerful words

17. When midazolam fails Short acting 1-3 hrs amnesic not analgesic in some people acts like alcohol –increase agitation and aggression Alcohol and benzo use affects its activity try Nozinan or Phenobarbitone

18. Terminal restlessness Look for reversible cause  Bladder, bowel, pain, hypoxia Best drug is midazolam  2.5mg – 5mg s/c midazolam  20 mg++ per 24 hrs midazolam  Or lorazepam SL

19. Sedation “If you want to die in your sleep you have to sleep first..”

20. Liverpool Care Pathway for the Dying ?? Stairway to Heaven Or ?? Improve everyones care to a minimum standard

22. Know who to ring !!! Know where the resources are ! Mount Vernon Cancer Network Advice 01923 844281 Hospices….open all hours Peri-patetic HUC Marie Curie Nurse OOH District Nurses