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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5230_Библиотеки_им_академика_М_И_Перельмана.pdf
243THINKING ABOUT DEATH
Place of death In 207, 46%
4
of all deaths occurred in hospital. Potential
advantages of an acute hospital include 24h access to healthcare professionals,
availability of interventions to relieve symptoms (eg drainage of pleural eusion), and reassurance that help will be available in an emergency. However,
the lack of privacy, noise, and restricted visiting hours may not suit all patients.
Other settings include home, care home, or hospice. As part of holistic planning towards the end of life, the potential advantages and disadvantages of each
setting should be discussed and the patient’s priorities and wishes identied.
Capacity Patients with cognitive impairment such as delirium or advanced
dementia may not be able to have discussions about death or have the capacity to make decisions about their care (E p. 30). These patients may also
struggle to report symptoms and may require additional nursing support with
the use of aids to identify discomfort (eg Abbey pain scale, PAINAD system).
Sources ofhelp The holistic assessment and treatment of patients
towards the end of life can be challenging and require dedicated time
which you may not have on the busy hospital wards. For help addressing
patients’ physical, spiritual, and emotional needs consider contacting:
• The palliative care team
• Macmillan nurses
• The acute pain team (usually part of anaesthetics)
• The chaplaincy.
DNACPR CPR is an invasive procedure that, if successful, usually re-
quires a signicant period in intensive care. Common side eects include
rib fractures and reduced mental and physical function. For patients with
advanced disease for whom CPR oers no realistic prospect of success,
a do not attempt cardiopulmonary resuscitation (DNACPR) decision may
be appropriate. This should be an individualized decision which is regularly
reviewed as a patient’s clinical condition changes. CPR is a treatment and
the decision to provide it remains with the medical team; a patient cannot
demand CPR. However, the wishes of the patient and their relatives
should be paramount and all decisions should be communicated clearly to
the patient and their relatives.
5
As a junior doctor, you may be involved in
discussions around resuscitation, though documentation usually requires a
signature from a senior clinician. Where there is disagreement, a second
opinion can be oered. A DNACPR decision does not override clinical
judgement (eg resuscitation in the unexpected event of choking).
K Box 7. Priorities at the end of life
In a UK study of 20 cancer patients, the most important factors associated
with a good death were ‘to have my pain/symptoms well controlled’, ‘to
not be a burden to my family’, and ‘to have sorted out my personal aairs’
respectively. Place of death was ranked as the seventh most important
factor. ‘Home’ was the preferred place of death for 42.5% of patients.
Mhttps://www.gov.uk/government/publications/older-people-who-died-in-hospital-england-207
The communication of DNACPR decisions was examined in Tracey vs Cambridge University Hospitals
(204). The judge acknowledged that discussing DNARs can be distressing to patients, but ruled that
unless doctors feel ‘the distress might cause physical or psychological harm’ the risks of the discussion are
outweighed by the benets (eg to autonomy, dignity, and their right to a private life and second opinion).
Waghorn M, et al. Opinions of patients with cancer on the relative importance of place of death in the
context of a ‘good death’.
BMJ Support Palliat Care 20;:30–4.
6
244 CHAPTER7 Care at the end of life
Symptom control in palliative care
K Palliative care is the active total care of patients with non-curative
disease. It involves the control of physical symptoms, integrates the psychological and spiritual aspects of care, and provides a support system
for patients and their relatives.
For advice, especially regarding complex or dicult symptom control,
contact the palliative care team.
Pain For all patients, a thorough pain history should be taken, with par-
ticular attention to the temporal pattern of the pain (acute, chronic, breakthrough, or upon a trigger such as moving). For more information on pain
history and prescribing E pp. 92, 22. Thinking about the mechanism of the
pain will help you choose the most appropriate analgesia (Table 7.).
Opioid prescribing in palliative care (E p. 92 for opioid conversions.)
Opioids are the mainstay of pain control in palliative care. Pain can be
divided into ‘opioid responsive’ and ‘non-opioid responsive’. Always prescribe a laxative and antiemetic alongside opioids unless contraindicated.
Initiating morphine in an opioid-naÏve patient Start with 2.5mg PO 2–4hrly and
ask the patient to request morphine whenever they have pain. Calculate the
total dose required over 24h for sucient pain control and divide it into a
morning and evening modied-release dose. Additional oral morphine can
be prescribed as PRN for breakthrough at ⅙ of the total 24h dose.
If the patient is already taking a weak opioid (eg codeine, tramadol) Stop the weak
opioid and give the equivalent dose as oral morphine with PRN for breakthrough pain at ⅙ of the total 24h dose. If pain is poorly controlled with frequent use of PRN morphine for breakthrough pain, the total 24h requirements
can be calculated and used to calculate an increased modied-release dose.
If the oral route is not feasible The doses can be given subcutaneously and
for predictable pain, a syringe driver can be set up to deliver the total
24h dose as continuous SC morphine.
Renal impairment Morphine can accumulate in renal impairment. Reduced
doses with a longer dosing interval can be used for patients with mild impairment, but fentanyl and alfentanil are safer analgesics for patients with
renal failure—seek specialist advice.
3 Signs of opioid toxicity include drowsiness, confusion, myoclonic
jerks. Reduce morphine dose by 30–50%.
Table7. Adjuvant analgesia
Pain Treatments
Neuropathic Gabapentin, pregabalin, amitriptyline, lidocaine patch
Bony NSAIDs, bisphosphonates
Bowel obstruction Hyoscine butylbromide, octreotide, corticosteroids
Incident pain (eg on
moving, showering)
†
Corticosteroids may be also be helpful for other pain associated with swelling or where there is an
inammatory cause, seek specialist advice.
Rapid-onset opioid taken prior to trigger (eg
sublingual fentanyl)
†
Nausea and vomiting The vomiting centre in the medulla receives inputs
from the cerebral cortex, vestibular apparatus, chemoreceptor trigger zone,
and GI tract, mostly mediated via D
nausea may include chemo/radiotherapy, drug therapy, constipation, pain, bowel
, 5HT
, and AChM receptors. Causes of
2
2/3
obstruction, hypercalcaemia, gastric stasis, hepatosplenomegaly, and concurrent infection. Antiemetics work by antagonizing these receptors and blocking
signals to the vomiting centre. For prescribing information see E p. 88. Nonpharmacological measures include relaxation techniques, avoiding strong odours,
having small and frequent snacks, and mouth care. For pharmacological measures,
the antiemetic choice depends on the most likely cause (Table 7.2).
Table7.2 Nausea in terminal illness
Cause Typical features Management
Chemical,
eg chemo/
radiotherapy,
drugs
Bowel
obstruction
Raised ICP Headache, confusion Cyclizine, dexamethasone
Vestibular Vertigo, may worsen with
Note: levomepromazine is a multipurpose antiemetic which may be eective 2nd
line if other antiemetics are ineective or when treating multifactorial nausea.
Severe persistent nausea not
relieved by vomiting, frequent
retching, small volume vomitus
Vomiting predominant (may be
faeculent), colicky abdominal
pain, early satiety
movement
Haloperidol,
metoclopramide,
ondansetron
Hyoscine butylbromide,
dexamethasone,
ondansetron
Cyclizine
Agitation The cause of the agitation should always be sought; pain,
urinary retention, and constipation are common causes. Midazolam is
st line (2.5–5mg/2h SC) but levomepromazine can also be considered
(6.25mg/2h SC, reduce dose in the elderly).
Breathlessness Can be multifactorial; seek and treat reversible causes.
Patients with large pleural eusion may benet from drainage. Practical
measures include ensuring good airow (eg opening a window), using a fan
next to the face, and sitting the patient upright. Oxygen, low-dose morphine PRN (eg .25–2.5mg/4h PO), or midazolam PRN (2.5mg/4h SC)
may also help. Respiratory secretions can be treated with glycopyrronium
(200micrograms/4h SC) or hyoscine butylbromide (20mg/4h SC).
Table7.3 Management of other symptoms inpalliativecare
Symptom Treatments
Constipation
Cough Saline nebs, antihistamines, simple/ codeine linctus, morphine
Dry mouth Chlorhexidine, sucking ice or pineapple chunks, consider
Hiccups Antacids, eg Maalox
Itching Emollients, chlorphenamine, cetirizine, colestyramine
E pp. 324–5, also bisacodyl
Candida (thrush) infection, synthetic saliva
(obstructive jaundice), ondansetron
®
, Gaviscon®, chlorpromazine, haloperidol
245SYMPTOM CONTROL IN PALLIATIVE CARE
246 CHAPTER7 Care at the end of life
Care in the last days of life
Recognizing the dying patient This can be dicult. Often patients
become gradually more fatigued and lethargic, with changes in communication and reduced oral intake which can lead to diculty taking oral medications. Signs that a patient is approaching death include a change in breathing
pattern (shallow, irregular, Cheyne–Stokes breathing), noisy respiratory
secretions, and drowsiness or reducing consciousness. Since considerable
uncertainty will always persist, eective and honest communication is vital,
along with regular review of treatment decisions by the senior responsible
clinician. Ensure DNACPR paperwork is completed (E p. 243) and anticipatory medications have been prescribed (Box 7.2).
Withdrawal of treatment For patients who have reached the nal
stage of their illness and are not expected to survive, the decision may
be taken by a senior doctor to withdraw active treatment and focus
on keeping the patient comfortable. These decisions and discussions are
highly emotive and should be handled with consideration and skill.
Stopping medicationsAdministering drugs may cause unnecessary
distress, particularly those aimed at prophylaxis of long- term conditions. Review all medications with a senior and stop those deemed to
be unnecessary. The decision to stop antibiotics can be a particularly
dicult one, but again, this is made easier by well- documented prior
conversations.
Hydration and nutrition at the end of life Concerns about de-
hydration and hunger at the end of life are common. Mouth care using
a sponge to moisten the mouth and supporting a patient to drink on
demand are helpful. Clinically assisted hydration (eg IV uid therapy) has
potential disadvantages in that the risk of uid overload and respiratory
secretions is higher as membranes become ‘leaky’ towards the end of
life. Patients can be supported to eat if they wish.
Box 7.2 Anticipatory medications, 'just in case meds'
These are PRN medications to treat common symptoms as a patient
approaches the end of life. They should be prescribed for patients in
all settings. In the community, the medications are usually dispensed in
advance and kept at the patient’s home (‘just in case box’) so that they
can be administered by a visiting nurse or GP more quickly.
Analgesic Pain
Antiemetic Nausea and
Anxiolytic Agitation
Antisecretory Respiratory
(breathlessness)
vomiting
(breathlessness)
secretions
Morphine 2.5–5mg/2h SC
Oxycodone 2.5–5mg/2h SC
Haloperidol 0.5–.5mg/2h SC
Levomepromazine 6.25mg/2h SC
Midazolam 2.5–5mg/2h SC
Levomepromazine 6.25mg/2h SC
Glycopyrronium bromide
200micrograms/4h SC
Hyoscine butylbromide 20mg/4h SC
Verification of death
Declaring death As a junior doctor you will often be asked to de-
clare that a patient has died. This is not an urgent request, but the patient
cannot be transferred to the mortuary until it is done. There may be
other members of sta who can do this if you are busy and unable to attend in a timely fashion. If you are uncomfortable doing this alone, or are
doing it for the rst time, ask another member of sta to accompany you.
The Academy of Medical Royal Colleges has guidance on the diagnosis
and conrmation of death from which the following advice is adapted,
but your hospital may have specic guidelines which you should follow.
. Conrming cardiorespiratory arrest You should observe
the patient for a minimum of 5min to conrm irreversible cardiorespiratory arrest has occurred:
• Listen for heart sounds in two places, for min in each place (total
2min),then
• Palpate over a central artery (carotid/ femoral) for min,then
• Listen for breath sounds in two places, for min in each place (total 2min).
It is common to hear transmitted GI sounds when auscultating the chest,
which should be ignored. However, in a very recently deceased patient it is
also not uncommon for a lone complex to appear on the ECG, or for them
to take a ‘last’ (agonal) breath. This or any other spontaneous return of cardiac or respiratory activity during your period of observation should prompt
a further 5min observation from the next point of cardiorespiratory arrest,
unless the patient is for active resuscitation.
2. Conrming the absence of motor response After 5min of
continued cardiorespiratory arrest conrm the absence of motor response in the patient:
• Absence of the pupillary response to light; the pupils will often be
dilated and they should not change when exposed to a bright light
source (eg pentorch)
• Absence of the corneal reex; passing rolled up cotton wool over the
edge of the cornea should not elicit a blinking response
• Absence of any motor response to supra orbital pressure; applying
rm supra orbital pressure should not elicit any motor response.
3. Documentation The time of death is recorded as the time at which these
criteria are fullled. Remember to sign and print your name and bleep number.
What happens to the patient after death? When a patient dies,
the nurses prepare the body, closing the eyes and jaw, washing the body, and
using pads to absorb any urinary or rectal leakage.
Lines and tubes are not removed since these will be inspected if a postmortem examination is undertaken. The patient is completely covered
with asheet. Once the death has been veried, the body can be taken
to the mortuary. Curtains and portable partitions are used to try and
screen this from other patients.
For more information see Mwww.aomrc.org.uk/reports-guidance/ukdec-reports-and-guidance/
code-practice-diagnosis-conrmation-death/
247VERIFICATION OF DEATH
7
248 CHAPTER7 Care at the end of life
After death
K In the UK, all deaths must be registered with the local registrar’s oce.
For this to happen, a doctor issues a ‘medical certicate of the cause of
death’ (MCCD, also confusingly referred to as the ‘death certicate’) which
must be taken to the registrar’s oce by a relative or deputy within 5d (8d in
Scotland). In certain circumstances, or when the cause of death is not clear,
the doctor must report the death to the coroner and the time limit does not
apply. Once the death has been registered, the registrar’s oce provides the
relatives with the ocial death certicate and a funeral or cremation can take
place. Cremation requires additional forms to be completed by a doctor.
Medical Certicate of Cause of Death
Where circumstances require involvement of the coroner’s oce/ procurator scal (E p. 252), do not complete the MCCD unless they instruct you todoso.
Eligibility The MCCD can be completed by any doctor who ‘attended’
the patient in the last 28d of life, or by a doctor who viewed the body
in person after death.
Medical examiners In England and Wales, hospital trusts must have a medical
examiner (usually a senior doctor), who is trained in the clinical and legal
aspects of death certication and oversees the completion of MCCDs.
This involves reviewing the proposed cause of death, discussing the cause
of death with the patient’s next of kin if they have questions or concerns,
and identifying cases for further review under local mortality arrangements.
Completing theMCCDMost of the entries are self- explanatory
• Name of deceased: full name of the deceased
• Date of death as stated to me: eg fteenth day of August2022
• Age as stated to me: eg 92years
• Place of death: ward, hospital, and city where theydied
• Last seen alive by me: eg fourteenth day of August2022.
Then circle just
. The certied cause of death takes account of information obtained
from post- mortem.
2. Information from post- mortem may be availablelater.
3. Post- mortem not beingheld.
4. I have reported this death to the Coroner for further action.
Then circle just
a. Seen after deathbyme.
b. Seen after death by another medical practitioner but notbyme.
c. Not seen after death by a medical practitioner.
Cause ofdeath For example:
I(a) Pulmonary embolism 6hours
(b) Fractured femur 7days
(c) Osteoporosis 30years
II Ischaemic heart disease 30years
one of these (most commonly option‘3’):
one of these (most commonly option‘a’):
8
:
Summarizing the cause of death can be dicult: it is important to take
advice from the consultant the patient was under. It is important to think
of this as a sequence of events leading up to the death of the patient.
The pathology listed in I(a) is whatever ultimately resulted in the patient
dying (eg intraventricular haemorrhage, myocardial infarction, meningococcal septicaemia); avoid using modes of death (Table7.4) as this may
lead to delays later in the process. The I(b) and I(c) entries should be the
pathology/ sequence of events which led up to I(a). Include pathology in II
which likely contributed to death but might not have necessarily been part
of the main sequence of events leading up to the death. It is not compulsory to have entries in I(b), I(c), or II and these can be left blank. Avoid
abbreviations.
Approximate interval between onset and death This gives the sequence of
events a timeframe.
The death might have been due toor contributed toby theemployment followed
atsome time bythe deceased
If you think the death was in any way related
to their employment or an industrial disease you should refer the case to
the coroner/ procurator scal for their consideration.
Signing thecerticate This requires your signature and medical qualica-
tions, alongside which your local oce will usually ask you to print your
name and often your GMC number. For ‘Residence’ it is acceptable to
enter the name of the hospital and the city. For deaths in hospital you also
need to enter the name of the patient’s consultant at the time ofdeath.
Completing thesidesMake sure you complete the stubs on either side of
the main form, copying exactly your entries o the mainform.
Completing theback If you have spoken to the coroner’s or procurator
scal’s oce, and they have decided it is appropriate for you to complete
the MCCD, they may ask you to circle one of the options and initial in
box Aon the reverse of theMCCD.
Table7.4 Causes and modes ofdeath
Causes of death (use these terms) Modes of death
Myocardial infarction, cardiac arrhythmia Cardiac arrest, syncope
Sepsis, hypovolaemia, haemorrhage,
anaphylaxis
Congestive cardiac failure, pulmonary
oedema
Bronchopneumonia, pulmonary embolism,
asthma, chronic obstructive pulmonary
disease
Cerebrovascular accident Collapse
Cirrhosis, glomerulonephritis, diabetic
nephropathy
Carcinomatosis, carcinoma of the… Cachexia, exhaustion
(avoid these terms)
Hypotension, shock, o legs
Heart failure, cardiac failure,
ventricular failure
Respiratory failure,
respiratory arrest
Liver failure, renal failure, uraemia
249AFTER DEATH
For government guidance on completing the MCCD see Mwww.gov.uk/government/publications/
guidance-notes-for-completing-a-medical-certicate-of-cause-of-death
250 CHAPTER7 Care at the end of life
Cremationforms
Cremation forms The main form to be completed for adult cremation is
‘Cremation form 4’ (Form B in Northern Ireland)— see ‘Completing
Cremation 4’. Other cremation forms are available for stillbirths, and for
the cremation of bodyparts.
Eligibility For deaths in hospital, it is expected that the person completing
Cremation 4 treated the deceased during their last illness and had seen
the deceased within 28d of death. Medical practitioners completing
Cremation 4 must hold a licence to practise with the GMC, which includes temporary or provisional registration.
Examining thebody The body must be examined after death to check the
patient’s identity and to identify any problematic implants for cremation
(Box 7.3). If you are required to view the body, check the notes, ECGs,
and X- rays for possible implants, but also examine the patient for scars
or palpable implants (pacemakers are usually, but not always, on the anterior chest wall). If you believe there is an implant, talk to the mortuary
sta who will be able to removeit.
Remuneration The completing doctor is currently paid £82 for Cremation
form 4 by the undertaker. The reason you are paid is because this is not
a standard NHS service and you are taking responsibility for the fact the
body will not be able to be exhumed for evidence if there is any doubt
in the future as to the cause of death. Cremation form fees are classed
as taxable income.
Box 7.3 Problematic implants forthe cremation
ofhuman remains
• Pacemakers; implantable cardioverter debrillators; cardiac
resynchronization therapy devices; implantable loop recorder
• Ventricular assist devices
• Implantable drug pumps including intrathecalpumps
• Neurostimulators and bone growth stimulators
• Hydrocephalus programmableshunts
• Any other battery- powered implant
• Fixion nails (intramedullary nails for xing long bone fractures)
• Brachytherapy implants
• Radiopharmaceutical treatment (via injection).
Completing Cremation4
Most of the questions are self- explanatory9:
• Details of the deceased:name, address, occupation
• Date and time of death, place ofdeath
• Are you a relative of the deceased?
• Have you any pecuniary interest in the death of the deceased?
• Were you the deceased’s usual medical practitioner? Generally it is
the patient’s GP who is regarded as the usual medical practitioner
• State for how long you attended the deceased during last illness. Eg 5days
• Please state the number of days and hours before the deceased’s death
that you last saw them alive. Eg day, 2hours
• Please state the date and time that you saw the body of the deceased
and the examination that you made of the body. Eg date, time, external
examination to conrm identify and check for implantable devices
• From your medical notes, and the observations immediately before and at the
time of the deceased’s death, describe the symptoms and other conditions
which led to your conclusions about the cause of death. Outline symptoms
in the period leading up to death; include date of admission to hospital
• Has a post- mortem examination been made? Usually the answer to
this is no, but if it has, tick yes and give details
• Please give the cause of death. Copy what appears on theMCCD
• Did the deceased undergo any operation in the year before their death?
If yes, give brief details
• Do you have any reasons to believe that the operation(s) shortened the
life of the deceased? If yes, the case should be discussed with your
seniors/ Medical Examiner/ coroner’s oce/ procuratorscal
• Please give the name and address of any person who nursed the deceased
during their last illness. Usually enter the name of the sister responsible
for the ward where the patient died, eg Sister Jayne Smith, Ward26
• Were there any persons present at the moment of death? If yes, give
details, asabove
• If there were persons present at the moment of death, did those persons
have any concerns regarding the cause of death? If yes, give details
• In view of your knowledge of the deceased’s habits and constitution
do you have any doubts whether about the character of the disease or
condition which led to the death? Yesorno
• Have you any reason to suspect the death of the deceased was:violent
(yes or no) or unnatural (yes orno)?
• Have you any reason at all to suppose a further examination of the
body is desirable? If yes, give details
• Has the coroner been informed about the death? If yes, give details
• Has there been any discussion with a coroner’s oce about the death
of the deceased? If yes, give details
• Have you given the certicate required for the registration of death? If
no, give the details of who has completed theMCCD
• Was any hazardous implant placed in the body? See Box7.3.
• If yes, has it been removed? Yesorno
• Sign, date, and enter your contact details.
9
For government guidance on completing cremation forms see Mwww.gov.uk/government/
publications/medical-practitioners-guidance-on-completing-cremation-forms
251AFTER DEATH
252 CHAPTER7 Care at the end of life
Referring patients to the coroner
The coronerThe coroner is a government ocial and is usually a lawyer but
may have joint degrees in law and medicine; their job is to investigate a death
when the cause of death is unknown or cannot readily be certied as being
due to natural causes. The coroner’s oce is staed by coroner’s ocers
(not medically or legally qualied), who take the majority of enquiries.
Making a referral tothe coronerAny case which meets the criteria in Box 7.4
should be referred to the coroner’s oce for their consideration; after
discussing the case, the coroner’s ocer may suggest it is appropriate for
the referring doctor to complete the MCCD. Occasionally the coroner’s
ocer will either take over the case, or wish to discuss it directly with the
coroner rst, and in these situations the MCCD should not be completed
by the referring doctor unless instructed to do so.
To refer, or not torefer? If you are in any doubt about whether to refer
to the coroner or not, speak rst to your seniors, or the local Medical
Examiner for advice.
Next steps The coroner may choose to hold an inquest which examines
the facts of the case. They will usually request written statements from
those involved in the care of the patient and you may be asked to attend
the inquest. They can also order a post-mortem examination to establish
the cause of death.
Box 7.4 Indicators for coroner's referral
• The cause of death is unknown
• It cannot be readily certied as being due to naturalcauses
• The death occurred during an operation or before full recovery from the
eects of an anaesthetic or was in any way related to the anaesthetic (in
any event a death within 24h should normally be referred)
• There are any suspicious circumstances or history of violence
• The death may be linked to an accident (whenever it occurred)
• There is any question of self- neglect or neglect byothers
• The death has occurred or the illness arisen during or shortly
after detention in police or prison custody (including voluntary
attendance at a police station)
• The deceased was detained under the Mental HealthAct
• The death is linked with an abortion
• The death might have been contributed to by the actions of the
deceased (such as a history of drug or solvent abuse, self- injury, or
overdose)
• The death could be due to industrial disease or related in any way
to the deceased’s employment
• The death may be related to a medical procedure or treatment
whether invasiveornot
• The death may be due to lack of medicalcare
• The death occurred within 24h of admission to hospital (unless the
admission was purely for terminalcare)
• It may be wise to report any death where there is an allegation of
medical mismanagement.
This note is for guidance only. If in any doubt, contact the coroner’s oce for further advice.