End of life care (Last hours and days of life)

1. Identifying a dying patient (diagnosing dying)
   1. Differentiate between patients with a malignant vs non-malignant diagnosis
2. Deciding whether to initiate life-sustaining treatments vs active palliative management.
   1. Withholding inappropriate life-sustaining treatments is easier than  withdrawing them
   2. Local legal requirements (ethical requirements will be covered separately)
3. Psychosocial care
   1. Communicating effectively with the family that the patient is dying
   2. Goals of care
   3. Preferred place of death (what resources are available if the family wants to take the patient home; ensuring adequate medication supply etc).
   4. Carer education on what to expect as the patient approaches death, mouth care, administration of medication, bowel and bladder care etc
4. Physical care
   1. Discontinue non-essential medications, monitoring, and treatments
   2. Appropriate drugs and route of administration
   3. Mouth, bowel, bladder cares
5. Spiritual care
6. Symptom management at the end of life
   1. (Most symptoms will be covered in separate talks)
   2. Terminal agitation
   3. Death rattle
   4. Anticipatory prescribing

References:

1. https://www.caresearch.com.au/caresearch/tabid/746/Default.aspx
2. Ellershaw J, Ward C. Care of the dying patient: the last hours or days of life. BMJ 2003;326:30-34
3. Scarre G. Can there be a good death? Journal of evaluation in clinical practice 2012;18:1082-1086
4. Palliative care formulary – PCF5
5. Hugel H et al. Respiratory tract secretions in the dying patient: A comparison between glycoyrronium and hyoscine hydrobromide. Journal of palliative medicine 2006;9(2):279-285
6. Irwin S.A Clarifying delirium management: practical, evidenced-based, expert recommendations for clinical practice. Journal of palliative medicine 2013; 16(4):423-435
7. Kapo J. Palliative care for the older adult. Journal of palliative medicine 2007;10(1):185-210
8. John L Schuster, Jr. Delirium, confusion, and agitation as the end of life. Journal of palliative medicine 1998;1(2):177-187
9. Fast facts: https://www.mypcnow.org/fast-facts