osteopathic epec osteopathic epec education for osteopathic physicians on end-of-life care based on...
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Osteopathic EPECOsteopathic EPEC Osteopathic EPECOsteopathic 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 AssociationAOA: Treating our Family and Yours
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12
Last Hours of Living
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Prognostication
• Skill of prediction and art of communication
• When?• Advise in terms of ranges:
hours to days days to weeks weeks to months
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . 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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12, Part 1
Physiological Changes, Symptom Management
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives
• Assess and manage the pathophysiologic changes of dying
• Care for the whole person, not just the symptoms
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Decreasing fluid intake . . .
• Oral rehydrating fluids
• Fears: dehydration, thirst
• Remind families, caregivers• Dehydration does not cause
distress
• Dehydration may be protective
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Decreasing fluid intake
• Parenteral fluids may be harmful• Fluid overload, breathlessness,
cough, secretions
• Mucosa / conjunctiva care
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Decreasing blood perfusion• Tachycardia, hypotension
• Peripheral cooling, cyanosis
• Mottling of skin
• Diminished urine output
• Parenteral fluids will not reverse
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Neurologic dysfunction• Decreasing level of
consciousness
• Communication with the unconscious patient
• Terminal delirium
• Changes in respiration
• Loss of ability to swallow, sphincter control
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Frequency of symptoms… last two weeks of life• Pain (51-100%)
• Dyspnea (22-46%)
• Asthenia (80%)
• Anorexia (80%)
• Dry mouth (70%)
• Mental confusion (68%)
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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)
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
2 roads to death2 roads to death
RestlessRestless
ConfusedConfused TremulousTremulous
HallucinationsHallucinations
Mumbling DeliriumMumbling Delirium
Myoclonic JerksMyoclonic JerksSleepySleepy
LethargicLethargic
ObtundedObtunded
Semi-comatoseSemi-comatose
ComatoseComatose
SeizuresSeizures
THE USUAL ROAD
THE USUAL ROAD
THE DIFFICULT ROAD
THE DIFFICULT ROAD
NormalNormal
DeadDead
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Decreasing level of consciousness• “The usual road to death”
• Progression
• Eyelash reflex
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Communication with the unconscious patient . . .• Distressing to family
• Awareness > ability to respond
• Assume patient hears everything
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . 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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Terminal delirium• “The difficult road to death”
• Medical management• Benzodiazepines
lorazepam, midazolam • Neuroleptics
haloperidol, chlorpromazine
• Seizures
• Family needs support, education
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Changes in respiration . . .• Altered breathing patterns
• diminishing tidal volume
• apnea
• Cheyne-Stokes respirations
• accessory muscle use
• last reflex breaths
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Changes in respiration • Fears
• Suffocation
• Management• Family support
• Oxygen may prolong dying process
• Breathlessness
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss of ability to swallow• Loss of gag reflex
• Buildup of saliva, secretions• Scopolamine to dry secretions
• Postural drainage
• Positioning
• Suctioning
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss of sphincter control• Incontinence of urine, stool
• Family needs knowledge, support
• Cleaning, skin care
• Urinary catheters
• Absorbent pads, surfaces
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Pain• Management when no urine
output• Stop routine dosing, infusions
of morphine
• Breakthrough dosing as needed (prn)
• Least invasive route of administration
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss of ability to close eyes• Loss of retro-orbital fat pad
• Insufficient eyelid length
• Conjunctival exposure• Increased risk of dryness, pain
• Maintain moisture
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Physiologic Changes and Symptom Management
Summary
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12, Part 2Expected Death
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives
• Prepare, support the patient, family, caregivers
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . As expected death approaches• Reinforce signs, events of
dying process
• Personal, cultural, religious, rituals, funeral planning
• Family support throughout the process
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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?”
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
… 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.”
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Signs that death has occurred . . .• Absence of heartbeat,
respirations
• Pupils fixed
• Color turns to a waxen pallor as blood settles
• Body temperature drops
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Signs that death has occurred• Muscles, sphincters relax
• Release of stool, urine
• Eyes can remain open
• Jaw falls open
• Body fluids may trickle internally
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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.
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
…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.”
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
After expected death occurs . . .• Care shifts from patient to
family / caregivers
• Different loss for everyone
• Invite those not present to bedside
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . 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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Moving the body
• Prepare the body
• Choice of funeral service providers
• Wrapping, moving the body• Family presence
• Intolerance of closed body bags
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
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
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Expected Death
Summary
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Module 12, Part 3
Loss, Grief, Bereavement
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Objectives
• Identify, manage initial grief reactions
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss, grief with life-threatening illness . . .• Highly vulnerable
• Frequent losses• Function / control /
independence
• Image of self / sense of dignity
• Relationships
• Sense of future
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Loss, grief with life-threatening illness• Confront end of life
• High emotions
• Multiple coping responses
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss, grief, coping
• Grief = emotional response to loss
• Coping strategies• Conscious, unconscious
• Avoidance
• Destructive
• Suicidal ideation
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Normal grief• Physical
• Hollowness in stomach, tightness in chest, heart palpitations
• Emotional• Numbness, relief, sadness, fear,
anger, guilt
• Cognitive• Disbelief, confusion, inability to
concentrate
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Complicated grief . . .
• Chronic grief• Normal grief reactions over
very long periods of time
• Delayed grief• Normal grief reactions are
suppressed or postponed
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
. . . Complicated grief
• Exaggerated grief• Self-destructive behaviors
eg, suicide
• Masked grief• Unaware that behaviors are a
result of the loss
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Tasks of the grieving
• Accept the reality of the loss
• Experience the pain caused by the loss
• Adjust to the new environment after the loss
• Rebuild a new life
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Assessment of grief
• Repeated assessments• Anticipated, actual losses
• Emotional responses
• Coping strategies role of religion
• Interdisciplinary team assessment, monitoring
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Grief management• If reactions, coping strategies
appropriate
• Monitor
• Support
counseling rituals
• If inappropriate, potentially harmful
• rapid, skilled assessment, intervention
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EEPPEECC
American Osteopathic AssociationAOA: Treating our Family and Yours
Loss, Grief, Bereavement
Summary