Care of the Imminently Dying Patient

July 8th, 2010

Christian Sinclair, MDKansas City Hospice & Palliative Care

Prognostication of the Terminal Phase

Working with Ranges - Minutes

Working with Ranges - Hours

Working with Ranges - Days

Death Trajectories

• Sudden Death

• Death from Acute Illness

• Death from Chronic Illness

• After Withdrawal of Life Support

Scales

• Palliative Performance Scale

• Palliative Prognostic Index

• Links available from:– prognosis.pallimed.org– EPERC Fast Facts

The Rally

What to Manage vs. What to Expect

What to Manage vs. What to Expect

Transforming from Patient-Centered Care to

Family-Centered Care

Time and logistics

Time and logistics

Time and logistics

Time and logistics

Time and logistics

Systems-Based Decline

Examination of the dying patient

Constitutional

Eyes & Oropharyngeal

Gastrointestinal

• Anorexia – Major family education point here – GI shut down – industrial analogy

• Cachexia – body image issues

• Decreased Fluid Intake – another major family education point

• Incontinence - dignity

Cardiovascular• Hypotension

– Hypovolemic– Cardiogenic– Septic

• Poor cap refill, cyanosis, mottling, edema

• Brady / Tachycardia– possible sign of distress body adjustment

• Implantable Devices– think ahead about deactivation

• Don’t forget about blood pressure meds

• Major prognostic value in imminent death

• Can be fooled with variation

Renal

Pulmonary

Skin Care

Neurological/Psychological

Considerations of Location

Spiritual/Existential Considerations

Medication Management

• Prognosis / Goal Mismatch– If not aligned then change the medications

• Pill Dysphagia- Think ahead for other options

• Alternate Routes– PR is not the only option– Topical medications – eh.

Unexplained Prolongation of the

Terminal PhaseNo one has really looked at this

population but it bears some examination.

For a copy of the slides, please email: csinclair@kchospice.org

• Recommended Reading/ Key References:

• Furst CJ, Doyle D. The Terminal Phase, Chapter 18, Oxford Textbook of Palliative Medicine, 3rd Ed.

• EPEC – Last Hours of Living, Module 12, 1999.

• Ferris FD, von Gunten CF, Emanuel LL. Competency in End-of-Life Care: Last Hours of Life. J of Pall Med. August 2003: 605-613.

• Plonk WM, Arnold RM. Terminal Care: The Last Weeks of Life. J of Pall Med 8(5): 1042-55