DIAGNOSING DYING: PHYSIOLOGY & MANAGEMENT FOR SPECIALISTSKyle P. Edmonds, MDAssistant Clinical ProfessorDoris A. Howell Palliative Care ServiceUC San Diego Health System

Adapted from Palliative Care International Curriculum, Ed. Frank R. Ferris

OVERALL MESSAGE

Diagnosis and management of dying is an overlooked aspect of medical care.

The family’s perception of the process can have long-term consequences.

Dying is not inherently uncomfortable. List the two high-risk end-of-life symptoms

requiring specialist-level management.

ANTICIPATORY GUIDANCE: LAST HOURS

Everyone will die < 10 % suddenly

Unique processes & risks

Little experience

ANTICIPATORY GUIDANCE: COMPLICATED BEREAVEMENT

Hx complicated bereavement Psych Hx / Dependent

personality Out of life-cycle norms Poor social support Absent frame of reference Sudden/violent death

Your Tools: Acetaminophen Bisacodyl Chlorpromazine Glycopyrrolate Lorazepam Morphine

concentrate Senna

MRS. A

A NOTE ON LANGUAGE

Adapted from Fig 2: Hui et al, 2014.

PRINCIPLES OF MANAGEMENT

Diagnose Anticipatory guidance Environment Assessment Acknowledge Fears

Serious Illness

Dx: Dying

Ongoing Care

Death Care after death

Recovery

Adapted from : Ellershaw & Ward, 2003.

NORMALIZE THE ENVIRONMENT

Family presence Turn off monitors Minimize meds / procedures Stop oxygen Include pt in conversations Touch

ASSESSMENT: COMFORTABLE?

PHYSIOLOGY OF DYING

Cardiovascular Renal Respiratory Gastrointestinal

HEENT Constitutional Neurological

VITAL SIGNS

Adapted from Fig 1: Bruera et al., 2014.

CONSTITUTIONAL

Terminal fever Pressure ulcer risk Symptoms: Weakness;

Fatigue; Joint position fatigue

FEVER

Fears: Discomfort, Hastened death

Management Noninvasive cooling Rectal acetaminophen

CARDIOVASCULAR

Tachycardia, hypotension Peripheral cooling, cyanosis Third-spacing Mottling of skin… Symptoms: dizziness,

edema

MOTTLING

RENAL

Decreasing urine output Diminished GFR (changing

pharmacokinetics) Symptom: generally

comfortable

RENAL CLEARANCE MORPHINE

Liver

Morphine M3G . . . M6G . . .

Analgesia CNS+ +++++++

Collins SL, et al. J Pain Symptom Manage. 1998.Mercadante S, Arcuri E. J Pain. 2004.

Urine90 – 95 %

PAIN: CONTINUOUS OPIOIDS & OLIGURIA

<20ml/hr (500ml/d): decrease

<10ml/hr (250ml/d): stop! Always: bolus for symptoms

RESPIRATORY

Patterns: Tachypnea, Apnea Chin-lift, jaw-jerk*

Diminishing tidal volume Oropharyngeal secretions* Symptoms: generally

comfortable

CHANGES IN RESPIRATION

Fear: Suffocation, dyspnea

Management Family support Oxygen variably effective Opioids (rarely)

SECRETIONS**

Fear: Choking, Drowning

Management Reassurance Positioning Glycopyrrolate

GASTROINTESTINAL

Loss of ability to swallow Dehydration Ileus Sphincter dysfunction

Symptoms: anorexia; nausea; dry mouth; incontinence

DECREASING FOOD INTAKE

Fear: Starvation,

Hastened Death Management

Normalize & Reframe Food for comfort Aspiration risk

PATIENT/FAMILY MEANING

“Food” = ?

PATIENT/FAMILY MEANING

No! “Food” =

DECREASING FLUID INTAKE

Fears: Thirst, Hastened Death

Management Reassure Benefit/Burden of IVF Oral care

LOSS OF SPHINCTER CONTROL

Fears: Indignity

Management Education & Support Diligent cleaning / skin care Urinary catheters? Absorbent pads / surfaces

HEENT

Open eyes Loss of retro-orbital fat pad Insufficient eyelid length

Slack Mouth

Symptoms: dry eyes; dry mouth

XEROSTOMIA / XEROPHTHALMIA

Fears: Thirst, Discomfort

Management Oral care Eye care

NEUROLOGICAL

Progressive decrease in LOC Preserved hearing & touch Delirium Pain not automatic!

Symptoms: Confusion; Drowsiness

PAIN

Fear: Uncontrolled pain

Assessment Grimace Physiologic signs Incident vs. rest pain Differentiation from delirium

RestlessConfused Tremulous

Hallucinations

Mumbling Delirium

Myoclonic JerksSleepy

LethargicObtunded

Semicomatose

Comatose

SeizuresUSUAL ROAD

DIFFICULT ROAD

Baseline

DeadNEUROLOGICAL: TWO ROADS TO DEATH

TERMINAL DELIRIUM**

Fear: Terror

Management Early Diagnosis Education & expectations Environment Proportional sedation

AFTER DEATH

Cardiopulmonary arrest Eyes often open Pupils fixed Jaw open Waxen pallor Muscles, sphincters relax

PRONOUNCING DEATH

“ Please come… ” Entering the room Pronouncing Documenting

WHAT TO DO WHEN DEATH OCCURS

Who to call… not ‘ 911 ’ No specific ‘ rules ’ Rarely any need for coroner Consider traditions, rites, rituals

COMMON GRIEF

BEREAVEMENT CARE

Bereavement care Attendance at funeral Follow-up to assess / support Assistance with practical

matters

OVERALL MESSAGE

Diagnosis and management of dying is an overlooked aspect of medical care.

The family’s perception of the process can have long-term consequences.

Dying is not inherently uncomfortable. List the two high-risk end-of-life symptoms requiring

specialist-level management.

REFERENCES

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