Elaine Bird

Jill Dickenson

Communication is Critical Consider communication difficulties & differences

Understand individual behaviour

Know individuals- cultural & spiritual concerns

Reflect as a team to ensure a consistent approach – staff

skills/own values in recognising symptoms can vary.

Knowledge of families their understanding, how they

express themselves, previous bereavement issues.

Allow time for care planning meetings

Decision Making Discussions about decisions for care & treatment are

of critical importance because of the progressive &

inevitable decline

Plan & discuss potential moral and ethical dilemmas

early - for example nutrition and hydration

Best interest – consider who should attend –plan

early

Document & communicate clearly - ambiguous

documentation can lead to inappropriate intervention

and miscommunication

Recognise Dying

Its very difficult to assess when a

person stops living with dementia &

starts dying from it

Group Work

5 minutes to discuss when would

you consider a person with a

dementia diagnosis is potentially

‘dying’ from the complications?

Indicators of End Stage Dementia Care Requires all care for activities of daily living

Unable to walk without assistance/ requires a hoist

Urinary & faecal incontinence

No consistent meaningful conversation

Vision, memory & hearing problems

Reduced dietary & fluid intake - increased risk of

aspiration, dry mouth

Weight loss

Recurrent infections

Scratching or picking at skin

Restlessness

Rigidity, facial grimacing, teeth grinding

Holistic Assessment for

individuals & their families

What do we mean by

holistic assessment

Physical Hearing & Visual problems

Pain & general discomfort

Nausea & Vomiting

Poor appetite & swallowing

difficulties

Respiratory Problems

Skin problems

Tiredness, restless increased

agitation.

Constipation & infections

Psychological

Depression & low mood

Poor sleep pattern

Disorientation/confusion

Anxiety /fear

Frustration

Grief- sense of loss

Social Worries about the future for

family

Financial burden

What's going to happen to

them

Family conflicts

Spiritual & religious Hope & creativity

To be listened to

Receive respect, honesty &

truthfulness

Religious practices, values,

cultures & beliefs associated with

dying.

Case Study 1. What are the indications that there is a

symptom problem

2. What could be the causes of the symptoms

3. What steps are you going to take to alleviate this problem

4. How & when will you review

Pain Difficult to interpret

Concerns strong analgesia causes increased

sedation & premature death

Uncontrolled pain impacts on quality of life

Assessment can be challenging even through

using recognised assessment tools

Effective care plans that are updated and identify

current pain management, moving & handling

techniques, positioning.

Importance of communication, education & team

work

Recognised Pain Assessment Charts for people with dementia

It is crucial staff consider a holistic approach to pain assessment

Pain tool chosen needs to be effective for individuals – no two people are the same.

Communication & training is critical for care team & relatives in how to use the tool

Abbey Pain Scale

PAINAD (Pain Assessment in Advanced Dementia)

Communication, Education & Documentation

Pain –the facts ‘Pain is whatever the patient says it is

and exists whenever he says it does.’

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage

Pain is NOT a normal aspect of ageing

Pain assessment is essential in the management of pain.

Nurses/carers are in the best position to assess, treat and evaluate pain

‘Pain is whatever the patient says it is

and exists whenever they says it does’ …

BUT

Many patients may not be able to:-

Communicate pain

Identify location of pain

Describe type of pain

Severity of pain

Types of Pain (will influence

medication prescribed) Soft Tissue Throbbing/tender/ache

Oedema Heavy/tight

Nerve Throbbing/burning/toothache

Raised intracranial pressure Thumping restricting

Bone Gnawing/aching

Colic Cramping/exhausting/gripping

Communication/Assessment/Evaluation

Principles in Managing Pain

Right Drug by the Ladder

Right dose by mouth/patch/injection

Right Time by clock

Clear documented evidence of description of pain

Clear documented evidence of outcomes from intervention.

Restlessness/agitation Unable to get comfortable

Scratching or picking at skin

Varying degrees of restlessness -

shouting, moaning twitching, jerking,

fidgeting, irregular breathing, plucking

at clothes/ sheets

Hallucinations

Causes Uncontrolled Pain

Dyspnoea

Retained secretions

Constipation

Urinary retention

Drugs – many drugs can cause cognitive decline, agitation, hallucinations & abnormal behaviour. Rationalise drug treatment.

Renal or liver failure.

Causes Metabolic – uraemia, hypercalcaemia,

hypoglycaemia, hypoxia from anaemia.

Infections – UTI, respiratory infections – treating

in some circumstances may be helpful in

reducing terminal restlessness

Cerebral – primary or secondary tumours

Anxiety – unresolved family conflict, denial , fear,

spiritual distress.

Withdrawal – of alcohol, narcotics or nicotine if a

heavy smoker.

Treatment Reassurance

Re-positioning

Consider reversible options – treat infection,

constipation, dehydration, medication review

Medication maybe appropriate

Benzodiazepines

Anti psychotics

Communication, Education & Documentation

Nausea

Identify the cause as this will affect treatment

Metabolic Renal Failure, Chest & Urinary Tract

Infections, Dehydration

Organic Constipation, Bowel obstruction

Medication

Psychological anxiety

Causes often unknown in EoLC

Assess, communicate, document Evaluate

Correct the correctable

Infections, medications, constipation

Non –pharmacological treatment Environmental factors posture, fresh air,

appropriate food, carers sat in the right position to

feed.

Small appetising meals

Good oral hygiene

Good bowel care – are laxatives effective or

required??

Diversional treatment- gentle music

Communication, Education and Documentation

Pharmacological treatment

If cause is gastro-intestinal poor gastric

emptying /reflux try metoclopramide, Domperidone

If cause is metabolic try haloperidol, Levomepromazine

If hyperacidity consider antacid, omeprazole, lansoprazole

If cause is psychological try lorazepam Evaluate Regularly

Respiratory Secretions

Common symptom at end of life

Distressing for resident family and

carers

Are oral antibiotics appropriate

Nursing care Turning the patient’s body gently onto their side

or turning the head to the side.

Reassure family.

Stop any fluids if not already done so if the patient is not swallowing.

Keep the mouth moist and clean

Apply lip balm.

Suctioning not recommend since this can increase distress and loosen more secretions.

Consider medication diamorphine /midazolam/buscopan