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Initial Assessment

  1. Recognize when a person may be in the last days of life (PCNOW #3)

    1. “Actively dying” or “imminent death” – Progress through stages from <24 hours to 14 days depending on prior health of patient

      1. Early: Bed bound, loss of interest or inability to eat, increased sleep/delirium

      2. Middle: Further mental decline to obtundation

      3. Late: Death “rattle,” coma, fever, fluctuating respirations, mottled extremities

      4. Actively dying: Physical changes include decreased BP; fluctuating HR, temperature, and respirations; clamminess; skin changes (flushed, bluish, pale yellowish pallor); congestion; extremities cool and purplish/blotchy; coma prior to death (NICE 2015)

  2. Gather information (NICE 2015)

    1. Patient's physiological, psychological, social, and spiritual needs

    2. Current signs and symptoms (including symptoms of imminent death listed above)

    3. PMH, clinical context, and underlying diagnosis

    4. Patient's goals, wishes, and views about future care

  3. Use a multidisciplinary team and consult if any uncertainty whether patient is declining, stabilizing, or recovering (NICE 2015)

  4. Monitor for changes every 24 hours (NICE 2015)

Communicate Prognosis to Patient, Surrogate Decision Makers, and Family

  1. Determine the needs and expectations of those dying (NICE 2015)

    1. If another person is desired to be present for decision making

    2. Current level of understanding of patient about his/her dying

    3. Cognitive status or any communicative special need

    4. Level of detail about prognosis

    5. Other cultural, religious, social, or spiritual needs

  2. Identify most appropriate team member to explain prognosis (NICE 2015)

  3. Discuss and document prognosis and preferences (NICE 2015)

    1. Give accurate information, explain uncertain, avoid false “hope”

    2. Discuss fears and anxieties

    3. Contact information for care team/family

    4. Preferences (if any) for last days of life

  4. Anticipate common questions from family (PCNOW #29)

    1. “Is he in pain; how do we know?”

    2. “Aren't we just starving him to death?”

    3. “Should I/we stay by the bedside?”

    4. “Can he hear what we are saying?”

    5. “What do we do after death?”

  5. Share decision making in advanced care planning (NICE 2015)

    1. Determine patient's mental capacity/level of involvement in decision making

    2. Determine if patient has an advance directive, durable power of attorney (DPOA)

    3. Determine patient's current goals/wishes or any cultural, religious, social, or spiritual preferences

    4. Offer provider contact details including afterhours contact information

    5. Provide individualized care

      1. Establish early resources (e.g., meals, equipment, caretaker support)

      2. Determine goals/wishes, preferred care setting, symptom management, care for after death, resource needs

      3. Record in chart and discuss with patient

      4. Revisit frequently the care plan with patient and family and update as needed

      5. If unable to meet wishes of patient, explain why

      6. Consult specialist advice if additional support needed (e.g., palliative care team)

Acute Medical Management

  1. Wean medications when impending death is recognized; taper certain medications to avoid withdrawal symptoms (i.e., proton pump inhibitors, steroids, chronic benzodiazepines, antidepressants)

  2. Assess and manage hydration (PCNOW #133, # 220, # 134, # 313, NICE 2015)

    1. Oral hydration

      1. Support the dying person to drink if they wish to

      2. Provide oral care ...

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