Osteopathic EPEC

1. 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

2. Module 12 Last Hours of Living American Osteopathic Association AOA: Treating our Family and Yours

3. 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 American Osteopathic Association AOA: Treating our Family and Yours

4. Prognostication • Skill of prediction and art of communication • When? • Advise in terms of ranges: • hours to days • days to weeks • weeks to months American Osteopathic Association AOA: Treating our Family and Yours

5. 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 American Osteopathic Association AOA: Treating our Family and Yours

6. . . . 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 American Osteopathic Association AOA: Treating our Family and Yours

7. Module 12, Part 1 Physiological Changes, Symptom Management American Osteopathic Association AOA: Treating our Family and Yours

8. Objectives • Assess and manage the pathophysiologic changes of dying • Care for the whole person, not just the symptoms American Osteopathic Association AOA: Treating our Family and Yours

9. 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 American Osteopathic Association AOA: Treating our Family and Yours

10. 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 American Osteopathic Association AOA: Treating our Family and Yours

11. 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 American Osteopathic Association AOA: Treating our Family and Yours

12. Decreasing fluid intake . . . • Oral rehydrating fluids • Fears: dehydration, thirst • Remind families, caregivers • Dehydration does not cause distress • Dehydration may be protective American Osteopathic Association AOA: Treating our Family and Yours

13. . . . Decreasing fluid intake • Parenteral fluids may be harmful • Fluid overload, breathlessness, cough, secretions • Mucosa / conjunctiva care American Osteopathic Association AOA: Treating our Family and Yours

14. Decreasing blood perfusion • Tachycardia, hypotension • Peripheral cooling, cyanosis • Mottling of skin • Diminished urine output • Parenteral fluids will not reverse American Osteopathic Association AOA: Treating our Family and Yours

15. Neurologic dysfunction • Decreasing level of consciousness • Communication with the unconscious patient • Terminal delirium • Changes in respiration • Loss of ability to swallow, sphincter control American Osteopathic Association AOA: Treating our Family and Yours

16. Frequency of symptoms… last two weeks of life • Pain (51-100%) • Dyspnea (22-46%) • Asthenia (80%) • Anorexia (80%) • Dry mouth (70%) • Mental confusion (68%) American Osteopathic Association AOA: Treating our Family and Yours

17. 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) American Osteopathic Association AOA: Treating our Family and Yours

18. 2 roads to death THE DIFFICULT ROAD Confused Tremulous Restless Hallucinations Normal Mumbling Delirium Sleepy Myoclonic Jerks Lethargic Seizures Obtunded THE USUAL ROAD Semi-comatose Comatose American Osteopathic Association AOA: Treating our Family and Yours Dead

19. Decreasing level of consciousness • “The usual road to death” • Progression • Eyelash reflex American Osteopathic Association AOA: Treating our Family and Yours

20. Communication with the unconscious patient . . . • Distressing to family • Awareness > ability to respond • Assume patient hears everything American Osteopathic Association AOA: Treating our Family and Yours

21. . . . 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 American Osteopathic Association AOA: Treating our Family and Yours

22. Terminal delirium • “The difficult road to death” • Medical management • Benzodiazepines • lorazepam, midazolam • Neuroleptics • haloperidol, chlorpromazine • Seizures • Family needs support, education American Osteopathic Association AOA: Treating our Family and Yours

23. Changes in respiration . . . • Altered breathing patterns • diminishing tidal volume • apnea • Cheyne-Stokes respirations • accessory muscle use • last reflex breaths American Osteopathic Association AOA: Treating our Family and Yours

24. . . . Changes in respiration • Fears • Suffocation • Management • Family support • Oxygen may prolong dying process • Breathlessness American Osteopathic Association AOA: Treating our Family and Yours

25. Loss of ability to swallow • Loss of gag reflex • Buildup of saliva, secretions • Scopolamine to dry secretions • Postural drainage • Positioning • Suctioning American Osteopathic Association AOA: Treating our Family and Yours

26. Loss of sphincter control • Incontinence of urine, stool • Family needs knowledge, support • Cleaning, skin care • Urinary catheters • Absorbent pads, surfaces American Osteopathic Association AOA: Treating our Family and Yours

27. 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 American Osteopathic Association AOA: Treating our Family and Yours

28. . . . Pain • Management when no urine output • Stop routine dosing, infusions of morphine • Breakthrough dosing as needed (prn) • Least invasive route of administration American Osteopathic Association AOA: Treating our Family and Yours

29. Loss of ability to close eyes • Loss of retro-orbital fat pad • Insufficient eyelid length • Conjunctival exposure • Increased risk of dryness, pain • Maintain moisture American Osteopathic Association AOA: Treating our Family and Yours

30. 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 American Osteopathic Association AOA: Treating our Family and Yours

31. 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 American Osteopathic Association AOA: Treating our Family and Yours

32. Physiologic Changes and Symptom Management Summary American Osteopathic Association AOA: Treating our Family and Yours

33. Module 12, Part 2 Expected Death American Osteopathic Association AOA: Treating our Family and Yours

34. Objectives • Prepare, support the patient, family, caregivers American Osteopathic Association AOA: Treating our Family and Yours

35. 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 American Osteopathic Association AOA: Treating our Family and Yours

36. . . . As expected death approaches • Reinforce signs, events of dying process • Personal, cultural, religious, rituals, funeral planning • Family support throughout the process American Osteopathic Association AOA: Treating our Family and Yours

37. 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?” American Osteopathic Association AOA: Treating our Family and Yours

38. … 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.” American Osteopathic Association AOA: Treating our Family and Yours

39. Signs that death has occurred . . . • Absence of heartbeat, respirations • Pupils fixed • Color turns to a waxen pallor as blood settles • Body temperature drops American Osteopathic Association AOA: Treating our Family and Yours

40. . . . Signs that death has occurred • Muscles, sphincters relax • Release of stool, urine • Eyes can remain open • Jaw falls open • Body fluids may trickle internally American Osteopathic Association AOA: Treating our Family and Yours

41. 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. American Osteopathic Association AOA: Treating our Family and Yours

42. …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.” American Osteopathic Association AOA: Treating our Family and Yours

43. After expected death occurs . . . • Care shifts from patient to family / caregivers • Different loss for everyone • Invite those not present to bedside American Osteopathic Association AOA: Treating our Family and Yours

44. . . . 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 American Osteopathic Association AOA: Treating our Family and Yours

45. Moving the body • Prepare the body • Choice of funeral service providers • Wrapping, moving the body • Family presence • Intolerance of closed body bags American Osteopathic Association AOA: Treating our Family and Yours

46. 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 American Osteopathic Association AOA: Treating our Family and Yours

47. 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 American Osteopathic Association AOA: Treating our Family and Yours

48. 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 American Osteopathic Association AOA: Treating our Family and Yours

49. Expected Death Summary American Osteopathic Association AOA: Treating our Family and Yours

50. Module 12, Part 3 Loss, Grief, Bereavement American Osteopathic Association AOA: Treating our Family and Yours