FINAL DAYS

THE LAST FEW DAYS

Dato’ Seri Dr T Devaraj

CEO/Medical Director PREDICTABLE ?
NCSM Penang Branch

ONSET OF FINAL DAYS - 1 ONSET OF FINAL DAYS - 2

1 - 3 MONTHS 1 - 2 WEEKS
! gradual withdrawal from people / ! Disorientation - agitation, hallucinating,
confusion, picking at clothes
world
! Physical – increase weakness, loss of interest in
! ↓ food intake food and drink, difficulty swallowing.
! sleeping ↑ drowsy, breathing changes, cold limbs,
oedema
! talking ↓

ONSET OF FINAL DAYS - 3 TASKS FOR DOCTORS

DAYS
" More drowsy or semi comatose
" + / - sips of water , difficulty swallowing
" Hearing often retained
" Irregular and or noisy breathing
" Changes pulse and blood pressure,
decrease
urine, bowels not open
" Peripheries cold or cyanosed
" Set goals of care with PT / FLY
" Patient – competent ? / wishes
" Aware of how family coping
! dynamics, fears
! desires
! culture, religion
! that family needs information, more
support
" Aware changes in condition of patient
" Anticipate manner and when death likely

The last few days/8th MHCongress 13-15 June 2008 1

 WANT TO GO HOME/DEATH AT
HOME
" Ensure - family knows how to care
needed medication / syringe driver
fluids / requires oxygen ?
discharge note / medical note for police
PCN informed
" Inform family – what to expect, what to do
signs of death
to inform PCN
how get burial & death certificate
" Bereavement support
FINAL DAYS - MANAGEMENT
“ care and comfort till the end”
“peaceful, dignified”
Principles
" Good nursing care
" Good symptom control
" Drugs - review route, stop non essential
" Avoid unnecessary intervention / DNR ?
" Food, fluids as needed
" Family – inform, explain, support
" Be available

TIME FOR GOOD NURSING

PAIN
Provide medication till end
“care and comfort” but
review drugs, dose
" Emotional support PT / FLY route:
" Positioning oral
" Nourishment, hydration sublingual
" Good mouth care transdermal
" Bladder, bowel, skin and wound care subcutaneous
rectal

MEDICATIONS BREATHLESSNESS
" Distressing and difficult symptom
" Any treatable condition?
" Essentials - analgesics, antiemetics,
" Oxygen
anticonvulsants, sedatives " Morphine, midazolam / route
" Nebuliser 0.9% saline / broncho d.
" Non essentials - hypotensives, " Secretions - hyoscine butylbromide
hypoglycemics, anti-depresants, 20 - 40 mgm sc prn
steroids " Positioning, fan, gentle suction
" ??? sedation

The last few days/8th MHCongress 13-15 June 2008 2

 CAUSES OF RESTLESSNESS AND
CONFUSION
" Drugs – Such as opioids, corticosteroids,
neuroleptics, alcohol (intoxication and
withdrawal)
" Physical – Unrelieved pain, distended bladder
or bowel, immobility or exhaustion, cerebral
lesions, infection, haematological, major
organ failure
" Metabolic upset – Urea, calcium, sodium,
glucose, hypoxia
" Anxiety and distress
WHEN DEATH ENSUES
" Respect, privacy
" Last offices
" Bereavement support
DEATH AND THE LIVING
" Carersmay need supports
" Reminder of our mortality
" Personal fears about dying and
death
" Opportunity evaluation own life
- what matters in life
The last few days/8th MHCongress 13-15 June 2008
RESTLESSNESS AND
CONFUSION
" Check medication
" Pain, full bladder, loaded rectum ?
" Quiet surroundings, soft light
" Someone familiar be with patient
" Reassure patient, family – not mad
" Anxiety – midazolam sc 2.5 – 5mg stat,
sc infusion 10 – 30mg/24h
" Agitation – haloperidol 1.5-3mg, sc 2.5-10mg,
sc infusion 5-30mg/24h
" D/D emotional, spiritual anguish
A GOOD DEATH
" Free from avoidable distress, suffering
" In accord with one’s wishes, culture
" Consistent with clinical and ethical
standards
" Company of loved ones
" Opportunity for farewells and fulfillment
" Achieve meaning of life
PURPOSE OF DEATH
“ If we all live and continue to increase as
we have done in the past,
the earth will be too small to hold us, and
there will be no room for
the cornfields. It is better that each of us
should live but a limited
time on this earth, then leave and make room
for the children”
Navajo Legend
3