END OF LIFE CARE anaesthesia and ccm .pptx

end of life care

1. END OF LIFE CARE PRESENTOR – DR PRATIBHA YADAV MODERATOR – DR ANURAG SIR DR SHIVANI MAM

2. INTRODUCTION End-of-life care focuses on providing comfort, respect, and dignity to individuals nearing the end of their lives. The goal is to relieve suffering, manage symptoms, and support both patients and their families through the process of dying. This care encompasses physical, emotional, social, and spiritual aspects to ensure quality of life, even in the final stages.

3. Definition of a good death Decent or good death is one that is free from avoidable distress and suffering for patients, families, and caregivers, in general accord with patients and families wishes; and reasonably consistent with clinical, cultural, and ethical standards”.

4. Key Elements of End-of-Life Care Symptom Management Pain Causes of pain in the terminal phase: 1. Disease progression 2. Change in dose or route of administration of analgesic 3. Pathological fracture 4. Constipation or urinary retention. 5. Pressure sores

5. Pain control may require parenteral administration of analgesics (subcutaneous, IV, patches. per rectal, sublingual ) as oral route may not be reliable . Managed with opioids (e.g., morphine ), non- opioid analgesics, and adjuvant therapies like anticonvulsants or antidepressants . • Do not use methods which interfere with communication and interaction with the patient . Pathological fractures can be treated by immobilization . • Pain due to pressure sores can also be relieved with topical Lignocaine and pressure reducing mattersses ..

6. 2.Dyspnea (shortness of breath) common causes are- extensive lung metastases or carcinomatous lymphangitis , anxiety or panic, chest infection, pleural effusion , pericardial effusion, and anaemia . Morphine is the drug of choice for symptomatic treatment of uncontrolled dyspnoea . If breathlessness is associated with recurrent panic, small doses of subcutaneous or IV Midazolam or Lorazepam sublingual or IV can be added.

7. 3. Urinary dysfunction As patients become weaker their ability to pass urine normally is affected by weakness and tiredness. Some patients will prefer to have catheter while for others the thought of a catheter or pads is very undignified. Patient's wishes need to be taken into account . unconscious it is important to ensure bladder care If such patients are managed at home, the family members need to be given clear instructions on how to manage an indwelling catheter at home as well as the use of pads.

8. 4. Death rattle seen in 25 to 92 per cent of dying patients the gurgling, bubbling noise made when a terminally ill patient has secretions at the back of the throat and is too weak either to swallow them or expectorate them . It is important to assure the family that the patient is not “choking to death.”

9. General measures include re-positioning the patient and giving reassurance to the relatives. • It is best to reduce the secretions with Atropine 0.6 mg sublingually or subcutaneously q6h or as and when required . Glycopyrronium bromide 0.6-1.2mg/24h subcutaneously is a good alternative. • Mechanical suction may be tried but it gives short lived relief only. In Palliative care settings, suction is rarely done as it can be traumatic .

10. 5 . Anorexia and dehydration : The patient is encouraged to eat as frequently as he/she desires . • Anorexia often increases as death approaches • The patient may be offered sips of water, crushed ice . 6 .Nausea and vomiting : Treated with anti-emetics like ondansetron , metoclopramide , or corticosteroids.

11. 7.Constipation : Managed with stool softeners, laxatives, and ensuring adequate hydration. 8. Anxiety and depression : Treated with counseling , medications (e.g., antidepressants or anxiolytics ), and emotional support.

12. B. Psychosocial and Emotional Support Emotional well-being : Many patients experience anxiety, fear, and depression during the end-of-life phase. Supportive counseling , therapy, and companionship are crucial. Family support : The emotional needs of family members also need to be addressed, as they may face grief, stress, and the burden of caregiving . Advance care planning : Discussing advance directives and living wills ensures that patients' wishes are respected, and decisions about treatment align with their goals.

13. C. Spiritual Care Patients often have spiritual or existential concerns during end-of-life care. Addressing these concerns can help bring peace. Chaplaincy services or other spiritual care providers may offer support regardless of the patient’s specific beliefs.

14. 2. Ethical and Legal Considerations A. Advance Directives Advance care planning ensures that patients’ preferences are known and honored . These documents include: Living Wills : Outline preferences for medical treatments. Durable Power of Attorney for Health Care : Designates a person to make medical decisions if the patient is unable. Do Not Resuscitate (DNR) Orders : Specify whether to attempt resuscitation if breathing or heart function stops.

15. B. Decision-Making and Informed Consent Patients must be fully informed about their prognosis, treatment options, and the potential benefits or burdens of interventions. Decision-making should be shared between healthcare providers, the patient, and their family.

16. C. Ethical Issues Ethical dilemmas often arise, such as decisions about the use of life-sustaining treatments (e.g., ventilators, feeding tubes) versus comfort-focused care . Euthanasia and physician-assisted death : These are controversial topics, and practices differ depending on legal and cultural contexts

17. 3. Palliative Care vs. Hospice Care Palliative care can be provided at any stage of a serious illness, focusing on symptom relief, regardless of whether the patient is seeking curative treatment. Hospice care is a form of palliative care specifically designed for patients in the final stages of life, typically when curative treatment is no longer pursued, and life expectancy is six months or less .

18. 4. Communication and End-of-Life Discussions A. Initiating Conversations Early and ongoing conversations about end-of-life care preferences are crucial. Healthcare providers should approach these discussions with sensitivity and empathy . Ask open-ended questions : "What are your hopes for the time you have left?" or "What are your biggest concerns about what lies ahead?“ B. Goals of Care Discussions Patients may prioritize comfort, autonomy, or life extension. Healthcare providers should help patients clarify their goals and align the care plan accordingly.

19. C. Breaking Bad News Providers should follow the SPIKES protocol for delivering bad news: S etting: Create a private, comfortable environment. P erception: Assess the patient’s understanding of their condition. I nvitation: Ask how much detail they wish to know. K nowledge: Share information clearly and compassionately. E motions: Address emotional responses. S trategy and Summary: Outline next steps and care options.

20. 5. Care Settings for End-of-Life Home care : Many patients prefer to die at home, surrounded by loved ones. Hospice services can provide medical and emotional support in the home environment. Hospice facilities : Dedicated hospice centers offer 24/7 care in a supportive setting. Hospital or nursing home care : For patients requiring complex medical management, hospitals or skilled nursing facilities may be appropriate.

21. 6. Cultural Considerations in End-of-Life Care End-of-life practices are influenced by cultural and religious beliefs . Healthcare providers should respect these practices, whether it involves specific rituals, prayers, or preferences about how care is provided. Cultural competence is critical, and providers should ask patients and families about any cultural or religious preferences they have for end-of-life care.

22. 7. Grief and Bereavement Support Bereavement support is offered to families both before and after a loved one’s death. It includes: Counseling services. Support groups. Information on coping with grief and loss.

23. 8. Withdrawal of Life-Sustaining Treatment Withdrawing treatment may be appropriate when it no longer contributes to the patient’s quality of life and is only prolonging the dying process. Common examples include discontinuing: Mechanical ventilation. Dialysis. Artificial nutrition and hydration. This decision should be based on the patient’s wishes, as expressed in advance directives or through discussions with family members and healthcare providers.

24. Conclusion End-of-life care is about dignity, comfort, and respect in the final stages of life. By focusing on symptom management, emotional and spiritual support, and respecting the patient's preferences, healthcare providers can improve the quality of life for both the patient and their loved ones during this critical time .

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