Recognise when death is imminent

2. Learning outcomes Recognise when death is imminent Share your own feelings about death and dying and the things you find difficult about caring for the dying Through group discussion explore what a ‘good death’ may mean List some of the concerns of the dying person and their family/whānau Discuss how to communicate with the dying person and how to address family concerns Describe the principles of caring for a person in the last days of life Discuss normal signs and symptoms of approaching death physically, emotionally and spiritually Explain how you will create a safe and peaceful environment for the person‘s final days Briefly discuss possible emergencies during the last days of life and how to manage them

3. Models of care

4. Cultural considerations at the end of life • What are the attitudes, values and beliefs you bring to your practice? • What are your rituals around death and dying? • What is the organisational culture? • Discuss the important role of the family at this time • Adapted from Waitemata Palliative Care Education Programme 2011

5. Dying • Dying is an important phase of life, one in which individuals have the right to expect quality of life to ensure a death with dignity occurs • The last days of life are unique for each person • Issues of spirituality, serenity and peacefulness are very important • It is a normal process • People don’t need to be in a darkened or hushed environment • Allow each family member their own time with the person in privacy • Encourage the family and whānau to be involved in their loved ones care as much as they wish to be • Allow them to talk about completion of practical business like wills,funeral arrangements, memories for children

6. What about you? • Write down some of your own feelings about death • What are some of the things you find difficult about caring for the dying?

7. Death is as unique for each person as a fingerprint

8. Dignity and quality of life • Promoting a sense of dignity and QOL are central to a palliative approach; • Adequate pain and symptom control • Avoiding inappropriate prolongation of dying • Relieving burdens • Achieving a sense of control • Strengthening relationships with loved ones

9. The final few days People experience increasing weakness and immobility, loss of interest in food and drink, difficulty swallowing, and drowsiness With an incurable and progressive illness, this phase can usually be anticipated, but sometimes a deterioration can be sudden and distressing Control of symptoms and family and whānau support take priority, and the nature of the primary illness becomes less important This is a time when levels of anxiety, stress, and emotion can be high for people, families and whānau It is important that the healthcare team adopts a sensitive yet structured approach

10. Principles of managing the last few days • Problem solving approach to symptom control • Avoid unnecessary interventions • Review all drugs and symptoms regularly • Maintain effective communication with the person, family, whānauand other members of the team • Ensure support for family and carers • Clearly document plan of care • Use ‘diagnosing dying’ flowchart

11. Change the focus • The focus of care changes • Quality of dying is important • Maintaining comfort and dignity: • positioning • mouth care • eye care • bladder and bowel care • skin care • Assessing and managing symptoms quickly

12. Emergency situations • Emergencies in the last days of life are rare • Most emergencies such as severe breathlessness or pain, haemorrhage or seizures in the last 48 hours are irreversible • Treatment should be aimed at the urgent relief of distress and associated symptoms • Medicines should be made available for immediate administration such as morphine, midazolam, haloperidol • Have someone stay with the person, family and whānau • Remain calm and act quickly to relieve distress

13. Haemorrhage Distressing and unforgettable for both people and their carers Haemoptysis (bleeding from the lungs), haematemesis (bleeding from the stomach), malaena (bleeding from the bowel) or erosion of a major artery such as the carotid are visually traumatic Prompt use of medicines – midazolam and morphine subcut Have dark coloured towels in the room Keep the person warm Explanations to family, whānau and other team members Don’t leave the person or family or whānau alone as they will be afraid

14. Retained airway secretions • Also known as “death rattle” • Explanation to family as to why it is occurring • Regular position changes • Cease intravenous/subcutaneous fluids • Administer medicines to help reduce the secretions • Suction – rarely indicated as suctioning increases secretions • Excellent oral care – could involve the family/whanau in doing this

15. Does it end here? • End of life care does not mean doing nothing and just letting the person die • It is not about “giving up” – it is about ‘being with’ the person • Withdrawal of life prolonging treatments doesn’t mean no treatment • It is active total care to provide the best quality of life until death • Excellent symptom control continues to the end • Emotional, spiritual and social wellbeing are ever present • Bereavement assessment tool

16. At the point of death Signs and symptoms of approaching death? Diagnosing death Organisational policies/rituals? Family/whānau/spiritual rituals? How long can the family stay if the person dies in a care facility? What happens if a person dies at home? Who tells the family? Closure?

17. You are important too • Work as a team • Good communication • Adequate time off duty/food/rest • Share feelings with other staff • Have strategies to preserve emotional and physical health • You matter, take care of yourself

18. Conclusion The needs of people who are dying and their families and whānau must always be at the centre of healthcare planningCompassion and loving kindness must be at the heart of our care

19. References New Zealand Palliative Care Handbook. (8th Edition). (2016. Available from http://www.hospice.org.nz/resources/palliative-care-handbook Ministry of Health. (2017). Te Ara Whakapiri: Principles and guidance for the last days of life and the Toolkit. Available from http://www.health.govt.nz/publication/te-ara-whakapiri-principles-and-guidance-last-days-life