Diagnosing Dying: Physiology and Management for Specialists

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    23-Aug-2014
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A review of the normal dying process for more expert physicians including physiology, management, family education and bereavement support. Reviews the common fears related to the dying process (for both families and healthcare professionals) and how to normalize and reframe those fears. Emphasizes the importance of anticipatory guidance for preventing complicated grief.

Transcript of Diagnosing Dying: Physiology and Management for Specialists

  • DIAGNOSING DYING: PHYSIOLOGY & MANAGEMENT FOR SPECIALISTS Kyle P. Edmonds, MD Assistant Clinical Professor Doris A. Howell Palliative Care Service UC San Diego Health System Adapted from Palliative Care International Curriculum, Ed. Frank R. Ferris
  • OVERALL MESSAGE Diagnosis and management of dying is an overlooked aspect of medical care. The familys perception of the process can have long-term consequences. Dying is not inherently uncomfortable. List the two high-risk end-of-life symptoms requiring specialist-level management.
  • ANTICIPATORY GUIDANCE: LAST HOURS Everyone will die < 10 % suddenly Unique processes & risks Little experience
  • ANTICIPATORY GUIDANCE: COMPLICATED BEREAVEMENT Hx complicated bereavement Psych Hx / Dependent personality Out of life-cycle norms Poor social support Absent frame of reference Sudden/violent death
  • Your Tools: Acetaminophen Bisacodyl Chlorpromazine Glycopyrrolate Lorazepam Morphine concentrate Senna MRS. A
  • A NOTE ON LANGUAGE Adapted from Fig 2: Hui et al, 2014.
  • PRINCIPLES OF MANAGEMENT Diagnose Anticipatory guidance Environment Assessment Acknowledge Fears
  • Serious Illness Dx: Dying Ongoing Care Death Care after death Recovery Adapted from : Ellershaw & Ward, 2003.
  • NORMALIZE THE ENVIRONMENT Family presence Turn off monitors Minimize meds / procedures Stop oxygen Include pt in conversations Touch
  • ASSESSMENT: COMFORTABLE?
  • PHYSIOLOGY OF DYING Cardiovascular Renal Respiratory Gastrointestinal HEENT Constitutional Neurological
  • VITAL SIGNS Adapted from Fig 1: Bruera et al., 2014.
  • CONSTITUTIONAL Terminal fever Pressure ulcer risk Symptoms: Weakness; Fatigue; Joint position fatigue
  • FEVER Fears: Discomfort, Hastened death Management Noninvasive cooling Rectal acetaminophen
  • CARDIOVASCULAR Tachycardia, hypotension Peripheral cooling, cyanosis Third-spacing Mottling of skin Symptoms: dizziness, edema
  • MOTTLING
  • RENAL Decreasing urine output Diminished GFR (changing pharmacokinetics) Symptom: generally comfortable
  • RENAL CLEARANCE MORPHINE Liver Morphine M3G . . . M6G . . . Analgesia CNS + +++ +++ + Collins SL, et al. J Pain Symptom Manage. 1998. Mercadante S, Arcuri E. J Pain. 2004. Urine 90 95 %
  • PAIN: CONTINUOUS OPIOIDS & OLIGURIA