Terminal care in home hospice

Presentation on common symptoms in palliative patients in terminal stage and regarding its management (2015)

1. Terminal Care in Home Hospice Care by Dr. Azhad Ahmed

2. Terminal Care Terminal care refers to care given during the last phase of a person’s illness. Needs a lot of palliative care skill to fulfil the wishes of the patient and those close to them. Patients usually have a rapidly changing clinical condition and also require psychological care.

3. Why Terminal Care? Nature of terminal phase and subsequent death have consequences for the bereaved. Allows patient to die with dignity in comfort, and in the place of their wish.

4. Terminal Care Physical symptoms Psychosocial needs Nursing care Comfort care kit, palliative sedation

5. Physical assessment 1 Pain Shortness of breath Nausea/Vomiting Agitation/Restlessness/Confusion Myoclonus and epilepsy Noisy breathing Urinary retention or incontinence

6. Physical assessment 2 Constipation Pressure areas/skin care Dry mouth Difficulty in swallowing Reversible complications/co-morbidities

7. Pain Pain – it is important to note that even a semi-conscious/uncommunicative patient can be in pain. New pains could occur in the last 48 hours. Parenteral or alternate routes of administration of drugs may need to be planned. Converting oral morphine to subcutaneous route would be helpful.

8. Pain Inj. Morphine 2.5mg s.c . can be kept standby. For those already on opioids, equivalent doses for s.c . administration can be given. Alternately, per-rectal administration of morphine can be given. Per-rectal administration of Paracetamol/NSAID suppositories are also an option.

9. Shortness of Breath Can be due to involvement of the lungs in primary disease. Alternately can be due to anxiety , anaemia, infection, asthenia or heart failure. Non-pharmacological measures like fans can be used. Opioids can be kept standby. Inj. Morphine 2.5mg s.c . or per-rectally can be given if needed.

10. Nausea and Vomiting Positioning of the patient would be useful to prevent aspiration. Antiemetics like Metoclopramide or Haloperidol can be given s.c . or by continuous infusion using a syringe driver. Metoclopramide 10mg s.c . prn / tds . Continuous infusion doses of 30 – 120 mg/day can be given.

11. Nausea and Vomiting 2 Inj. Haloperidol 5-20 mg/day in divided s.c . d oses or via syringe driver.

12. Restlessness/Agitation/Confusion Confusion is common in advanced illnesses Occurs upto 75% in the last days of illness Symptoms include drowsiness, poor concentration, disorientation, poor short-term memory, inappropriate behaviour . Misperceptions, delusions of hallucinations can occur.

13. Restlessness/Agitation/Confusion Rarely severe agitation or aggression may occur. Warning signs: emotional unease or anguish, fluctuating disorientation, visual hallucinations, paranoid ideas .

14. Restlessness/Agitation/Confusion Management would be to: Keep the patient safe Treat reversible causes Ensure patient is in a suitable environment Acknowldge the distress and fears of the patient and give reassurances where possible

15. Restlessness/Agitation/Confusion Reversible causes to look for include: Uncontrolled pain Full bladder / Constipation Discomfort due to immobility Dyspnoea / Hypoxia Brain metastasis Mental/Emotional causes Drugs Biochemical causes (liver/renal failure, hypercalcemia )

16. Management: Inj. Haloperidol: loading dose 2-5 mg, daily dose 5-10 mg Inj. Midazolam : loading dose 2-5mg, daily dose 5-30 mg (drug of choice for anxiety/anguish) Diazepam oral/rectal: loading dose 2-10mg, daily dose 6-20 mg. Alternately intermittent dose of Lorazepam starting at 1mg can be given. [uptodate.com]

17. Myoclonus Myoclonic jerks can occur in terminally ill patients. Can be due to electrolyte abnormalities, disease itself, or drugs (strong opioids, anticholinergics). Consider reducing or stopping drugs where possible.

18. Myoclonus Diazepam: pr/oral, 5-10mg repeated every hour, then 10-20mg at night for prevention. Midazolam s.c ., 2.5 – 5mg repeated every hour; 10-30mg/24hrs infusion.

19. Epilepsy Control of epilepsy would require first-aid measures (turning to the side if possible, supplemental oxygen if available). If already on oral medications, alternate routes of administration may be used. Sedatives can be added to existing medications.

20. Epilepsy Diazepam: pr, 5mg stat. Can be repeated after 15 minutes. Midazolam sc 2.5 – 5mg (0.1-0.2mg/kg) repeated every hour; 10-30mg/24hrs infusion. For refractory seizures: Clonazepam 0.25 – 0.5 mg po / ng bd / tds . Alternately Phenytoin 300mg om . OR Levetiracetam ( Keppra ) 500mg bd. Hospice or hospitalisation can be considered.

21. Noisy breathing Common in the terminal phase. No evidence to suggest that it disturbs the patient, but maybe distressing to the relatives or caregivers. Non-pharmacological measures: Position on the side or on semi-prone position. Good mouth care. Stop or reduce parenteral fluids to <500ml/day.

22. Noisy breathing It is important to explain to the family that patient is not starving or choking to death. Pharmacological: Atropine 1% eye drops 1-2 drops every 4-6 hours. Hyoscine 20mg sc and continuous infusion 40-120mg/day.

23. Urinary retention / Constipation Urinary retention can be due to disease (prostate), drugs or constipation. Bed-side commode or diapers can be considered. Cathetrisation may be required. Drugs like anticholinergics may need to be stopped. Enema and suppositories can be used to treat constipation.

24. Pressure sores Can be relieved by use of appropriate mattresses. Air/foam mattresses. Static air filled/fluid-filled mattresses. Work by distributing the pressure over a large area.

25. Psychosocial needs

26. Psychosocial needs Need to look for: Fear - of the diagnosis, mode of death, drug side effects Guilt – becoming a burden, past experiences Anger – loss of dignity, missed opportunities, loss of independence Uncertainty – spiritual questions, prognosis, future of the family Depression

27. Needs of the family Assessment of physical, financial and social needs of the family may need to be done. Should have access to palliative care professionals, 24-hours for advise/care. May need training to enable then to contibute to patient’s care.

28. Artificial hydration Family members may think patient will die hungry. May notice that patient’s mouth and lips are dry. Needs discussion of Pros and Cons with family. Potential harm from fluid overload or use of invasive cannulas should be discussed. Patient would require hospitalisation if family wants artificial nutrition. Hydration can be done subcutaneously in a home care setting with Normal saline 0.9%, 500ml per day.

29. Nursing care Terminal care may involve care of wounds/pressure sores with appropriate dressing. Patients may have feeding tube or catheters in place which require care. Fall prevention by environment or behavioural change may be required.

30. Palliative sedation Refers to administration of sedative medications to reduce conciousness to render intolerable and refratory suffering tolerable. Aim being to relieve symptoms and not to shorten life in a patient who is imminently dying (considered as 14 days). Indications: Agitated Delerium , Dyspnoea, Pain, Convulsions, Emergencies like massive haemorrhage or stridor

31. Palliative sedation Options include conscious sedation vs deep sedation. Medications: Inj. Midazolam 1-2.5 mg sc/iv stat and continuous infusion 0.5-2 mg/hr, with dose titrated to achieve desired level of sedation. Inj. Phenobarbitone 200mg iv/sc bolus and continuous infusion 600mg/day (600-1600mg/day).

32. Comfort care kit Useful to treat terminal symptoms in home care setting. Has numbered medications, with instructions on when and how to use. Medications and routes of administration tailored for ease of use. These include: Paracetamol suppository, Morphine (per-rectal), Haloperodol (sublingual), Lorazepam (sublingual), Atropine eye drops (sublingual).

33. References The Bedside Palliative Medicine Handbook, TTSH Handbook of Palliative Care, Second Edition (Christina Faull, Yvonne H. Carter, Lilian Daniels ) www.uptodate.com .

34. Thank You