Miscellaneous: End-of-Life Care

End-of-Life Care

Presentations

  • Syndrome of Imminent Death
    • Seen in Terminally Ill When Actively Dying
    • Decreased Function
    • Decreased Hunger & Thirst
    • Difficulty Swallowing & Clearing Secretions (“Death Rattle”)
    • Urinary & Bowel Incontinence
    • Aware of Surroundings & Situation Despite Delirium & Hallucinations
  • Air Hunger
    • Feeling of Severe Breathlessness
    • Seen in Terminally Ill When Actively Dying
    • Management: Sit Up, Increased Air Movement/Fan & Supplemental Oxygen
      • Consider Morphine & Benzodiazepines

Futility of Care

  • Treatments That Will Not Accomplish Intended Goal or Risks Greatly Outweigh Benefits
  • Types:
    • Quantitative Futility: Intervention Unlikely to Produce Intended Result
    • Qualitative Futility: Intervention Could Produce Intended Result, But Would Not Change Outcome
  • In General, Futile Care Should Not Be Performed
  • Specific Situations:
    • May Continue Aggressive Cares for a Pending Religious Ceremony
    • May Continue Mechanical Ventilation for Short Period in Brain Dead Patients for Family Grieving or Organ Donation

Organ Donation

  • Physicians Should Consult Organ Donation Services
  • Discussions:
    • Facilitated by Organ Services Representative
    • Physicians Themselves Should Not Have the Conversation Directly
  • Any Inconsistencies in Patient Wishes Should be Investigated by Organ Donation Service, Not Hospital Ethics Committee

DNR Orders at Surgery

  • “Required Reconsideration” – Patients and Caregivers Must Reexamine DNR Orders Before Surgery
  • Patient’s Do Not Have to be Full Code or Rescind a DNR Order to Undergo Surgery

Types of Care

  • Palliative Cares
    • Goal: Maximize Comfort & Quality of Life
    • Does Not Limit Treatment Options
    • Good Consideration if Family Disagrees with Goals of Care
    • Asymptomatic Patients Cannot Be Palliated
  • Comfort Cares
    • Only Comfort Measures are Provided
    • No Curative Measures
  • Hospice
    • A Form of Comfort Cares
    • Prerequisite: Life Expectancy < 6 Months
    • Treatment Goal: Palliative (Not Curative)

Comfort Care Measures

  • General Considerations:
    • Comfort Status DNR/DNI
    • Discontinue All Orders (Labs, Vital Signs, etc.) Not Essential for Comfort
    • Discontinue All Medications Not Essential for Comfort
    • Remove Invasive Monitoring (Arterial Lines, PA Catheters)
    • Discontinue Bedside Monitors & Silence Alarms
    • Discontinue Any Implanted Defibrillator
    • Terminal Withdrawal from Mechanical Ventilation
  • Pain Management: Opioids (Morphine, Hydromorphone or Fentanyl)
  • Dyspnea Management: Opioid Boluses Until Comfortable
    • Also Consider Nebulizer Treatments
  • Secretion Management: Oral Suctioning & Medications
    • Glycopyrrolate 0.2 mg IV Every 2 Hours as Needed
    • Hyoscyamine 0.125 mg Sublingual Every 4 Hours as Needed
    • Scopolamine Patch Every 3 Days if Needed
  • Anxiety Management: Lorazepam (Ativan) 0.5 mg PO/IV Every 30 Minutes as Needed
  • Delirium/Agitation Management: Haloperidol IV
  • Other Common Concerns:
    • Nausea
    • Constipation
    • Fever

Euthanasia

  • Passive Euthanasia: Withdrawal of Care
  • Active Euthanasia: Physician Administers Lethal Dose of Medication
  • Physician-Assisted Dying: Physician Prescribes Lethal Dose of Medication, Patient Administers
  • Double Effect Rule: Palliative Medication Foreseeably but Unintentionally Hastens Death
    • Ex. Morphine Analgesia Slows Respiratory Rate

Family Responsibilities After Death (“What to Do Next”)

  • Two Potential Responsibilities:
    • Call Clergy (If Applicable)
    • Call Funeral Home – Will Work with Hospital to Move & Prepare Body
  • Hospitals Have Social Workers Able to Help Families Navigate the Process