Priority 5 - Plan & Do.

Individual plan of care delivered with compassion

Jacquie UptonHospice at Home Lead

Early opportunity to discuss, record and update patients wishes and preferences as apart of individualised care planning

Extent of dying persons, their families/carers wishes for involvement

Views, beliefs and values respectedRemember a person is deemed to have

capacity unless proven otherwiseIndividual plan of care “agreed,

communicated, adhered to and regularly reviewed” by all involved

Planning Care

Undertake a holistic assessment for end of life needs and preferences in partnership with the patient, family/carers.

Integrated approach with other health and social care professionals involved

Assessment

Physical needs Emotional Social Psychological Spiritual needs Cultural and religious

Assess and respond sensitively to:

Assessment never stops!Subtle changes are significant and importantNeed to listen to family and carers they know

their loved oneCommunicate, share, record and document

changes and actions taken with clear rationale so all involved have an understanding

Explanation to patient and family crucial

Continual Assessment

Assessing

There will come a point when a patient will not safely be able to eat or drink.

Informed choice - The patient may continue to try eating and drinking and risk aspiration, choking if they have capacity this needs to be respected

Family and friends understanding benefits and burdens around dehydration at the end stages of life

General Medical Council 2010 guidance – Treatment and care towards the end of life: good practice in decision making and relevant clinical guidelines.

Food and Drink

Southern Health and Solent NHS have medicines administration orders for Syringe drivers and PRN medication

These are supposed to be universal across the areas to minimise drug administration error

A clear rationale needs to be assessed and recorded prior to administration

Honouring of DNACPR by professionals Referring to SPCT as needed

Symptom Control

Anticipatory –foresee, act in advance ofGenerally -only drugs needed are:

Analgesics for pain Anti-emetics for nausea & vomiting Anti-cholinergics for resp secretions or

‘death rattle’ Sedatives/anti-convulsants for

agitation

Explain to patient and family Important Conversations

Anticipatory medications at End of Life

Patient unable to take oral medication and has been symptomatic Nausea and vomiting Unable to swallow Weakness Confusion Coma

Poor alimentary absorption Medication more effective given by alt. route Bowel obstruction

Indications for a syringe driver:

IMPORTANT !!!!!!

Medications need to be regularly reviewed and adjusted to give optimum effect and alleviate risk of toxicity.

Is a subjective and abnormal feeling or sensation which the patient experiences.

Is a feeling of something being 'not quite right' about one's body and is usually uncomfortable or, at least, unwanted.

May occur suddenly or be present for a while. May occur intermittently or may become

progressively worse. A patient may experience several symptoms at

the same time. The symptom (including its severity) is

something that only the patient can truly know

A Symptom

Several symptoms may be inter-related and by treating one you may well relieve others

A patient may be in such pain that he or she is unable to move around, and needs to take regular codeine for pain relief.

Constipation (if a laxative is not taken at the same time.)

The patient’s pain allowing them to move around more freely, thus improving their bowel movements

Underlying Symptoms

Pain (often several types simultaneously)

BreathlessnessNausea/vomitingRespiratory secretionsNoisy breathingPressure area damageConfusionAgitation/restlessnessElimination problems-Urinary

incontinence/retentionDry/sore mouthFatigue

Most commonly reported symptoms…

Unrelieved pain causes unnecessary harm and suffering

Pain diminishes activity, appetite, sleep and quality of life

Pain further debilitates already weakened patients Full pain assessment/ using a pain tool validates

the patients pain, helps patient to describe pain more accurately, increases the reporting

Provides understanding of the personal experience of

pain and the impact that pain Measuring severity of pain helps to understand the

effectiveness of our intervention

Importance of accurate assessment

How would you assess or recognise a persons pain?

Assessment of Pain

TOTAL PAIN

Source: Twycross & Wilcock (2001)

Spiritual:• Why has this happened to me?• Why has God allowed this?• What’s the point of it all?• Is there any meaning or purpose to

this?• Can I be forgiven for past

wrongdoing?

Social:• Worry about

family• Job + prestige

loss• Loss of social

status• Family role loss• Isolation• Abandonment

Physical:• Other symptoms• Adverse effects of

treatment• Insomnia and chronic

fatiguePsychological:• Anger at delay in

diagnosis• Anger at

therapeutic failure

• Disfigurement• Fears of pain• Fears of

helplessness

• Sore mouth• Earache• Difficulty in

going to the toilet

• Painful joints• Painful sores• Uncut fingers

or toes• Being in same

position for a long time

• Being moved uncomfortably

• Where are my family

• Where are my friends

• Loss of independence

• Loss of confidence

• Loss of social networks

• Loss of role or job

• How do I belong here?

• Loss of abilities in relation to activities I love

• Why me?

• Loss of home• Loss of

confidence• Loss of self

esteem• Loss of loved

ones• Anger and

frustration

Physical Social

SpiritualEmotional

There are a variety of pain assessment tools to choose from. Here are a fewVisual Analogue Scale: patient is asked to

mark a point on the line to represent the intensity of the pain from none to worst pain

Numerical Rating Scale: patient is asked to score the pain from 0 to 10 where 0 represents no pain and 10 represents worst pain

Descriptive Words Scale: a patient is asked to use a list of adjectives to describe pain intensity ranging from none to worst

Pain Tools

The Pain Assessment in Advanced Dementia (PAINAD)

Dolopus 2 A Faces Rating Scale Abbey pain tool Disdat

Pain Tools

PPQRST Pain Assessment Tool-Factors…. So ask… So consider…

P Palliative What makes it better? What improves it?

Heat pads, distraction etc.

P Provokes What makes it worse?

Movement, deep breathing.

Q Quality What is it like? Be descriptive

Sharp, stabbing, dull, ache.

R Radiation Does it spread? Where?

Referred pain.

S Severity How bad is it? How does it affect your life?

T Timing Is there a pattern, time the pain comes on? What makes it worse

Can we change an activity to help?

Pain Assessment Tools

Pain assessment tools

Example

Good pain management requires the patient to give a good history of their pain

Try to optimise the patient’s own ability to report and describe pain

Take collateral histories from carers if necessary

Summary of pain assessment

Things that lower the pain threshold

InsomniaFatigueAnxietyFearAngerBoredom

SadnessDepressionSocial isolationSocial

abandonment

Pain-

Not all patients will experience pain, so be mindful of creating an

expectation!

The WHO Analgesic Ladder

Usually start with immediate release

morphine Every 4 hours, 2.5mg -10mg,

with the prn equal to the 4hrly dose

If using modified release morphine,

give 10mg-30mgbd, depending on

previous weak opioid,

Starting Opioids – To gain control of the pain

Start low and titrate upRegular dose of IR (immediate

release) preparation and PRN (1/6th of total)

Prescribe a laxative – opioids nearly always cause constipation!

Watch for nausea/vomiting (usually wears off after a few days)drowsiness, confusion/hallucinations

General Principles of using Strong Opioids

Strong OpioidsImmediate Release Modified Release

Morphine Liquid (Oramorph)Tablet (Sevredol)Injection (Morphine Sulphate)

Usually capsules but some preparations are tablets

Diamorphine Injection None available

Oxycodone Liquid (Oxynorm)Capsule (Oxynorm)Injection (Oxynorm)

Tablets (Oxycontin)

Fentanyl InjectionLozenges (Actiq)Buccal and sublingual preps

Patch – dose expressed in mcg/hr, changed every 72 hours

Buprenorphine Sub lingual tablets Patch – dose expressed as mcg/hr, some patches changed every 72 hours, others every week

Methadone Liquid, tablets, Injection. Due to different pharmacokinetic properties, as stored in fat cells, no immediate release preparation

Oral morphine to sc morphine

Calculate daily dose of oral morphine

Divide total oral dose by 2Sub cut morphine is 2x as strong as oral morphine

This is the equivalent daily (24hr) dose of morphine

Insufficient analgesia Cognitive impairmentSedationNauseaConstipation – fentanyl and buprenorphine are

less constipatingRenal impairment – morphine is excreted by the

kidneys, so may accumulate in renal failurePruritusMyoclonus

Reasons for Switching Opioids

Respiratory depression almost never a problem in cancer pain if

used sensiblyAddiction almost never a problem in cancer painOnly for the terminal phase definitely has a role for severe pain at any

stage in the disease trajectoryHastens death – NOT if used appropriately and

sensibly

Myths about Morphine

signs of toxicity

DrowsinessConfusionPin point pupilsMyoclonic jerksNausea/vomitingHallucinations (auditory/visual)Respiratory depression

Complementary therapiesAcupunctureTouch/massageReflexologyAromatherapyArt therapy/music therapyPsychological supportReassuranceGood communicationSpiritual counselling

Other Approaches

Think about a time when you have witnessed someone struggling with a symptom.

What happened?

Case Scenario

What symptoms or factors can cause agitation?

Agitation

Look for reversible cause and treat if appropriate Pain Urinary retention Drugs Infection Constipation Haemorrhage Anxiety Terminal agitation

Agitation

Multi-professional approach if terminal agitation need to work together as a team to manage this affectively

Assess the patient rule out what factors are exacerbating the agitation i.e. place a catheter in for retention

Listen to patients and relatives is there an opportunity to discuss anger, fear or guilt issues. Can the chaplain or their own religious leader facilitate?

Drug therapy assess which medication would be beneficial for their agitation. Rule out other symptoms such as pain or breathlessness first.

Management of Terminal Agitation

Midazolam a short acting benzodiazepine which helps to reduce anxiety and aggression, relaxes muscles, suppresses seizures and sedates.

Levomepromazine an antipsychotic which has a longer action for sedation in terminal agitation. It can act as an anti-emetic

Haloperidol an antipsychotic for agitated delirium. Also acts as a anti-emetic

What medications help with terminal agitation/restlessness?

Aromatherapy: there are certain essential oils which can aid grief and distress for both patient and family

Soothing music: enquire from patient or relatives what kind of music they like

Environment: is the room too hot or cold?

Spiritual care: does the Chaplain or Vicar need to come in to perform a religious intervention or does a figure head from another religion need consulting? “Unfinished business”

Reassurance: touch, voice, calmness, need to talk

Non-Pharmaceutical Interventions

Identify the cause of nausea and vomiting Treat the cause if possible and appropriate Target the antiemetic to the specific cause Use the oral route if mild nausea Use the subcutaneous route with severe

nausea, or if vomiting

Nausea & Vomiting - Key points on management

Haloperidol as an anti emetic (Also acts as a antipsychotic for agitated delirium) May cause jerking

Review dosage after 24hours. If two or more PRN doses given, then consider syringe driver

Levomepromazine as an anti emetic (Also acts as a antipsychotic) May cause hypotension, drowsiness, dry mouth and other anticholinergic effects

Cyclizine antihistamine with anticholinergic action (Avoid in heart failure) Can irritate the skin needs to be mixed with WATER and not Saline

What medications help with Nausea & Vomiting (EOL)

Mouth – coated tongue, candida etc Environment – sights, smells, bad

tastes, tablet burden Anxiety - ?use of lorazepam esp. if

anticipatory N&V Memory, fears

Don’t forget…

Try repositioning patient Stop infusion or NG feed Anticholinergics can reduce volume of secretions if

given in time Hyoscine Butylbromide 20mg – 120mg via syringe driver

over 24 hrs, 20mgs upwards PRN Hyoscine Hydrobromide (sedation effect) 400mcg –

2.4mg via syringe driver over 24 hrs, 400mcg sc prn Breathlessness 1.0 -2.5mg of immediate release oral

morphine 4 hourly prn & titrate upwards

Explain to family – Be clear about what the “noise is”

Breathing - Secretions ‘Death rattle’

Environment–room temp, ventilation, reassurance Consider whether patient is already taking oral

morphine for breathlessness If the patient is not already taking morphine ensure

prn morphine Sulphate 5-10mgs or diamorphine 2.5 - 5mgs prn is prescribed

If patient is already taking morphine ensure appropriate prn dose sc morphine prescribed

Convert to syringe driver with appropriate dose morphine/diamorphine

Lorazepam 0.5-1mg S/L(quick acting) for acute crisis and panic attacks

Medications to consider with sensation of Breathlessness (EOL)

Potential symptoms are multiple Assess and ensure PRN meds available Identify and plan care Rule out reversible causes Include spiritual & social assessment Evaluate effect of any interventions Communicate plan with Next of Kin Always document and record rationale

Summary : Symptoms at End of Life

Thank you