Palliative Care

• Expected physiological changes near death

  Changes in obs

  Weakness & fatigue

  Decreased oral intake & swallow reflex

  Decreased blood perfusion

  Renal failure

  Incontinence/retention of urine

  Change in mental state
• Keys to a 'successful' death

  MDT approach & communication

  Good communication with family & HCPs

  Seek advice or refer early to specialist palliative services

  Anticipate probable needs, so immediate responses can be made
• What are the routes for palliative drug treatment?

  SC

  Buccal, rectal, topical

  NOT IM (due to pain)
• Syndrome of imminent death


  24hrs - 2 wks

  Family education & anticipatory guidance is key -> 'these are symptoms associated with the normal dying process'

  Early phase

  • bedbound, incontinent
  • decreased oral intake
  • cognitive changes

  Middle phase

  • tracheal congestion
  • more cognitive changes
  • no oral intake

  Late phase

  • comatose
  • temp instability
  • altered resp pattern
  • mottling & cool extremities
  • absence of peripheral pulses
• Communication with the unconscious pt


  Assume pt hears everything

  Create familiar environment

  Include in conversations

  Importance of touch
• General approach to palliative care

  Transition to comfort care

  Stop interventions & monitoring that are not contributing to comfort

  Treat symptoms & educare

  Provide excellent oral & skin care

  Be present & honest, sit down, assist with family concerns/conflicts

  Attend to own emotional responses & support
• What main symptoms need to be managed at end of life?

  Respiratory tract secretions

  Restlessness/agitation

  Breathlessness

  Nausea & vomiting

  Pain
• How to manage respiratory tract secretions at end of life?

  Educate family

  Don't over hydrate

  Positioning

  Suctioning (rare)

  Cover or mask (music)

  Meds - butylbromide, hydrobromide
• How to manage restlessness/agitation at end of life?

  Consider reversible causes

  Unresolved psychological or spiritual issues

  Consider role of sedation (start low & titrate - midazolam, haloperidol)
• How to manage nausea & vomiting at end of life?

  Cause-specific approach

  Meds - metoclopramide, haloperidol, cyclizine, levomepromazine
• How to manage breathlessness at end of life?

  Reduce perception of breathlessness

  Reduce associated distress

  Can use opioids & benzodiazepines
• How to manage pain at end of life?

  Opioid SC
• What is a palliative care emergency?

  Any unexpected change in the condition of, or symptoms/circumstances in a patient with a life-limiting illness
• Physical palliative care emergencies

  Bone (crush, fracture, metastasis)

  Hypercalcaemia

  SVC obstruction

  Spinal cord compression

  MI

  DVT/PE

  Gastric/duodenal ulcer

  Infection/neutropenic sepsis

  Haemorrhage

  Seizures
• How to approach palliative emergencies?

  Assess nature of emergency

  How reversible is it

  Recent performance status, extent of disease

  Any co-existent co-morbidities

  Effectiveness of treatment vs burden

  Pts wishes & preferences