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Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of- Life Care Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational use. American Osteopathic Association AOA: Treating our Family and Yours

Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association

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Page 1: Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association

Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic EPEC Education for Osteopathic Physicians on End-of-Life

Care

Based on The EPEC Project, created by the American Medical Association and supported by the Robert Wood Johnson Foundation. Adapted by the American Osteopathic Association for educational

use.

American Osteopathic AssociationAOA: Treating our Family and Yours

Page 2: Osteopathic EPEC Osteopathic EPEC Education for Osteopathic Physicians on End-of-Life Care Based on The EPEC Project, created by the American Medical Association

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American Osteopathic AssociationAOA: Treating our Family and Yours

Module 12

Last Hours of Living

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American Osteopathic AssociationAOA: Treating our Family and Yours

Last hours of living• Everyone will die

• < 10% suddenly

• > 90% prolonged illness

• Last opportunity for life closure

• Little experience with death• Exaggerated sense of dying

process

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Prognostication

• Skill of prediction and art of communication

• When?• Advise in terms of ranges:

­ hours to days­ days to weeks­ weeks to months

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Preparing for the last hours of life . . .• Time course unpredictable

• Any setting that permits privacy, intimacy

• Anticipate need for medications, equipment, supplies

• Regularly review the plan of care

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. . . Preparing for the last hours of life• Caregivers

• Awareness of patient choices

• Knowledgeable, skilled, confident

• Rapid response

• Likely events, signs, symptoms of the dying process

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American Osteopathic AssociationAOA: Treating our Family and Yours

Module 12, Part 1

Physiological Changes, Symptom Management

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Objectives

• Assess and manage the pathophysiologic changes of dying

• Care for the whole person, not just the symptoms

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Physiologic changes during the dying process• Increasing weakness, fatigue

• Decreasing appetite / fluid intake

• Decreasing blood perfusion

• Neurologic dysfunction

• Loss of ability to close eyes

• Pain

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Weakness / fatigue• Decreased ability to move

• Joint position fatigue

• Increased risk of pressure ulcers

• Increased need for care• Activities of daily living

• Turning, movement, massage, OMT

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Decreasing appetite / food intake• Fears: “giving in,” starvation

• Reminders• food may be nauseating

• anorexia may be protective

• risk of aspiration

• clenched teeth express desires, control

• Help family find alternative ways to care

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Decreasing fluid intake . . .

• Oral rehydrating fluids

• Fears: dehydration, thirst

• Remind families, caregivers• Dehydration does not cause

distress

• Dehydration may be protective

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. . . Decreasing fluid intake

• Parenteral fluids may be harmful• Fluid overload, breathlessness,

cough, secretions

• Mucosa / conjunctiva care

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Decreasing blood perfusion• Tachycardia, hypotension

• Peripheral cooling, cyanosis

• Mottling of skin

• Diminished urine output

• Parenteral fluids will not reverse

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Neurologic dysfunction• Decreasing level of

consciousness

• Communication with the unconscious patient

• Terminal delirium

• Changes in respiration

• Loss of ability to swallow, sphincter control

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Frequency of symptoms… last two weeks of life• Pain (51-100%)

• Dyspnea (22-46%)

• Asthenia (80%)

• Anorexia (80%)

• Dry mouth (70%)

• Mental confusion (68%)

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Signs of active dying

• Retained audible respiratory secretions - death rattle (24-60 hours)

• Respirations with mandibular movement (jaw movement increases with breathing) (2-5.8 hours)

• Cyanosis of extremities (1-5 hours)

• No radial pulse (1-3 hours)

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2 roads to death2 roads to death

RestlessRestless

ConfusedConfused TremulousTremulous

HallucinationsHallucinations

Mumbling DeliriumMumbling Delirium

Myoclonic JerksMyoclonic JerksSleepySleepy

LethargicLethargic

ObtundedObtunded

Semi-comatoseSemi-comatose

ComatoseComatose

SeizuresSeizures

THE USUAL ROAD

THE USUAL ROAD

THE DIFFICULT ROAD

THE DIFFICULT ROAD

NormalNormal

DeadDead

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Decreasing level of consciousness• “The usual road to death”

• Progression

• Eyelash reflex

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Communication with the unconscious patient . . .• Distressing to family

• Awareness > ability to respond

• Assume patient hears everything

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. . . Communication with the unconscious patient• Create familiar environment

• Include in conversations• assure of presence, safety

• Give permission to die

• Touch – the power of touch can provide comfort, caring

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Terminal delirium• “The difficult road to death”

• Medical management• Benzodiazepines

­ lorazepam, midazolam • Neuroleptics

­ haloperidol, chlorpromazine

• Seizures

• Family needs support, education

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Changes in respiration . . .• Altered breathing patterns

• diminishing tidal volume

• apnea

• Cheyne-Stokes respirations

• accessory muscle use

• last reflex breaths

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. . . Changes in respiration • Fears

• Suffocation

• Management• Family support

• Oxygen may prolong dying process

• Breathlessness

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Loss of ability to swallow• Loss of gag reflex

• Buildup of saliva, secretions• Scopolamine to dry secretions

• Postural drainage

• Positioning

• Suctioning

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Loss of sphincter control• Incontinence of urine, stool

• Family needs knowledge, support

• Cleaning, skin care

• Urinary catheters

• Absorbent pads, surfaces

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Pain . . .• Fear of increased pain

• Assessment of the unconscious patient• Persistent vs fleeting expression

• Grimace or physiologic signs

• Incident vs rest pain

• Distinction from terminal delirium

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. . . Pain• Management when no urine

output• Stop routine dosing, infusions

of morphine

• Breakthrough dosing as needed (prn)

• Least invasive route of administration

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Loss of ability to close eyes• Loss of retro-orbital fat pad

• Insufficient eyelid length

• Conjunctival exposure• Increased risk of dryness, pain

• Maintain moisture

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Medications• Limit to essential medications

• Choose less invasive route of administration• Buccal mucosal or oral first, then

consider rectal• Subcutaneous occasionally• Intravenous rarely• Intramuscular almost never

• Add intravenously, rarely

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Medical futility

• Won’t achieve the patient’s goal

• Serves no legitimate goal of medical practice

• Ineffective more than 99% of the time

• Does not conform to accepted community standards

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Physiologic Changes and Symptom Management

Summary

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Module 12, Part 2Expected Death

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Objectives

• Prepare, support the patient, family, caregivers

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As expected death approaches . . .• Discuss

• Patient / family wishes• Status of patient• Realistic care goals• Role of physician /

interdisciplinary team

• What patient experiences what onlookers see

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. . . As expected death approaches• Reinforce signs, events of

dying process

• Personal, cultural, religious, rituals, funeral planning

• Family support throughout the process

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Counsel about palliative care interventions• Be clear about intent of intervention

“We would like to increase his morphine dose because we are concerned that he might be experiencing some pain (or shortness of breath).”

• Inquire as to understanding of action and concerns

“What is your understanding of the proposed actions. Do you have any concerns?”

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… Counsel about palliative care interventions• Address spoken (and unspoken)

concerns

“We do not believe this action will hasten death, nor is this the intent.”

“Our goal is to enable him to die a natural and peaceful death, letting it unfold at its own pace.”

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Signs that death has occurred . . .• Absence of heartbeat,

respirations

• Pupils fixed

• Color turns to a waxen pallor as blood settles

• Body temperature drops

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. . . Signs that death has occurred• Muscles, sphincters relax

• Release of stool, urine

• Eyes can remain open

• Jaw falls open

• Body fluids may trickle internally

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Telephone notification of death

• Inquire as to where the person is and whether alone (if driving while on a cell phone, advise the person to pull over and park)

• Identify self, relationship to the deceased (physician/nurse on-call), give brief advanced alert (I’m sorry I have some bad news.”) and give the news

• Listen more than you speak. If questions arise, answer them briefly. For more detailed inquiries, reassure the caller that these can be answered later.

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…Telephone notification of death

• Do NOT say that the person must come in right away – give permission to let feelings settle; suggest coming in with a family member or friend

• Give clear instructions as to where to go and whom to contact when arriving at the hospital, home or facility

• Finish with an empathic statement, such as “This must be very hard for you…Please let me know if there is anything else I can do to help.”

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After expected death occurs . . .• Care shifts from patient to

family / caregivers

• Different loss for everyone

• Invite those not present to bedside

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. . . After expected death occurs• Take time to witness what has

happened

• Create a peaceful, accessible environment

• When rigor mortis sets in

• Assess acute grief reactions

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Moving the body

• Prepare the body

• Choice of funeral service providers

• Wrapping, moving the body• Family presence

• Intolerance of closed body bags

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Other tasks• Notify other physicians,

caregivers of the death• Stop services• Arrange to remove equipment /

supplies

• Secure valuables with executor

• Dispose of medications, biologic wastes

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Bereavement care• Bereavement care

• Attendance at funeral

• Follow up to assess grief reactions, provide support

• Assistance with practical matters• Redeem insurance

• Will, financial obligations, estate closure

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Dying in institutions

• Home-like environment• Permit privacy, intimacy

• Personal things, photos

• Continuity of care plans

• Avoid abrupt changes of settings

• Consider a specialized unit

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Expected Death

Summary

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Module 12, Part 3

Loss, Grief, Bereavement

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Objectives

• Identify, manage initial grief reactions

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Loss, grief with life-threatening illness . . .• Highly vulnerable

• Frequent losses• Function / control /

independence

• Image of self / sense of dignity

• Relationships

• Sense of future

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. . . Loss, grief with life-threatening illness• Confront end of life

• High emotions

• Multiple coping responses

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Loss, grief, coping

• Grief = emotional response to loss

• Coping strategies• Conscious, unconscious

• Avoidance

• Destructive

• Suicidal ideation

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Normal grief• Physical

• Hollowness in stomach, tightness in chest, heart palpitations

• Emotional• Numbness, relief, sadness, fear,

anger, guilt

• Cognitive• Disbelief, confusion, inability to

concentrate

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Complicated grief . . .

• Chronic grief• Normal grief reactions over

very long periods of time

• Delayed grief• Normal grief reactions are

suppressed or postponed

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. . . Complicated grief

• Exaggerated grief• Self-destructive behaviors

eg, suicide

• Masked grief• Unaware that behaviors are a

result of the loss

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Tasks of the grieving

• Accept the reality of the loss

• Experience the pain caused by the loss

• Adjust to the new environment after the loss

• Rebuild a new life

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Assessment of grief

• Repeated assessments• Anticipated, actual losses

• Emotional responses

• Coping strategies­ role of religion

• Interdisciplinary team assessment, monitoring

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Grief management• If reactions, coping strategies

appropriate

• Monitor

• Support

­ counseling­ rituals

• If inappropriate, potentially harmful

• rapid, skilled assessment, intervention

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Loss, Grief, Bereavement

Summary