Anticipating & Planning for Common Problems at Home
Many problems in the last days of life can be predicted and prepared for:
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| Anticipated Problem | Consider & Plan |
|
Loss of mobility. Unable to transfer safely |
Generally safer and more manageable to nurse in bed Consider loan of hospital bed/monkey pole/cot sides/commode/ urine bottles Assess for pressure area care and implement appropriate strategy Indwelling urinary catheter/sheath for men is more acceptable if incontinent/unable to transfer to commode Bowel care |
|
Loss of ability to eat |
Prepare family and patient for this happening Explain it is a natural process Forcing food may create discomfort if too weak to swallow/digest |
|
Loss of ability to drink |
Prepare family and patient for this happening Explain it is a natural process and may aid comfort by reducing secretions/gastric secretions and chance of vomiting/urine output Encourage sips/mouth care If still distressed by thirst consider S/C fluids (N.saline 1 litre over 12 hour via a butterfly into anterior abdominal wall or thigh)* |
|
Loss of ability to shallow |
Convert essential medications to subcutaneous route (if no syringe driver available) |
|
Delirium and agitation |
Common at the end of life: Distressing and frightening for everyone involved Haloperidol 1.5-30mg/24h SC and/or midazolam 5-60mg/24h SC (if agitation only) |
|
Pain |
Morphine SC prn in proportion to overall opioid requirement (can be administered orally if injection not appropriate) Leave pre drawn-up syringes: leave an indwelling butterfly needle SC |
|
Vomiting |
Cyclizine 50mg tds SC or Buccastem 3mg sublingual or Transdermal hyoscine |
|
Dyspnoea |
Common and frightening Morphine preferably SC (or orally) titrated up as for pain Midazolam 2-10mg SC or buccal prn or 5-30mg SC/24h for breathlessness/fear or Diazepam |
|
Excess respiratory secretions |
Positioning/portable suction (if available) Hyoscine 0.4mg sublingual or SC 4h prn or Hyoscine 1.6-2.4mg/24h SC Hyoscine transdermal patch |
|
Changing breathing pattern |
Explanation to family "He may appear to stop breathing for a time, then draw another breath" |
Table: Anticipating & Planning for Common Problems at Home
Adapted from Guidelines on managing predictable problems in home
death
with permission from Dr. Mike Harlos, Manitoba, Canada.
*N. saline, 4% dextrose/0.18% saline or 5% dextrose are all suitable. No more than 2 litres/24 hours should be infused into any one site. Fluid should not be pumped in.
Our knowledge of the likely problems allows us to anticipate and plan for appropriate medical and nursing interventions. Each day or each visit aim as you leave to anticipate what might happen over the next day or two.
© Dr. Eileen Palmer, Dr John Howarth Palliative Care for the Primary Health Care Team Quay Books ISBN 1856422291