Dr Jessica Borbasi chats to James Edwards about palliative medicine. You will learn more about the role of palliative care and crisis medications for end of life care. We will discuss the Clinical Excellence Commission’s guidelines on the prescribing of anticipatory medicines for symptoms experienced in the last days of life. Are you aware of any contraindications? Is there a role for subcutaneous fluids? We will also go through an example case to put this all into perspective.
Summary Writer: Jane McDonnell
Script Writer: Jessica Borbasi
Editor: Jessica Borbasi
Interviewee: Jessica Borbasi
Dr Jessica Borbasi is an Advance Trainee in Palliative Medicine. After completing her basic physicians training she took a year off to work at a think tank, the Centre for Independent Studies. She is the author of “Life Before Death: improving palliative care for older Australians” and is passionate about educating doctors and the public about the true nature of palliative medicine, particularly its ability to improve living not just dying.
With Dr Jessica Borbasi, Advanced Trainee in Palliative Care Medicine at Greenwich Hospital, New South Wales, Australia
Palliative care is about end of life care. Its focus is on enabling people to live better with chronic or terminal illnesses in the period before they die. A landmark trial in palliative care medicine demonstrated that those patients with metastatic lung cancer who received early referral to palliative care had a better quality of life and lived longer.
An 89-year-old man has come to the wards from ED diagnosed with sepsis and metastatic lung disease. He has a fever, tachypnoea and back pain and has been started on IV antibiotics, but no NFR form completed. His recent CT shows metastatic spread to the spine and liver. Upon review, he is refusing any tests and is agitated, removing his nasal prongs. He is competent, understands his diagnosis and requests to be kept comfortable. His family members and the admitting team are in consensus.
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MasonNovember 11, 2018 at 9:02 pm
Thanks for this great talk, the points about the ‘death rattle’ were particularly eye interesting.
I’d be interested to know if Glycopyrollate is thought to have any negative effect or just no evidence or benefit?
Jessica BorbasiNovember 12, 2018 at 3:15 pm
Thank you for your comment. Below is some information – Don’t forget that anticholinergic side effects can include- dry mouth, confusion, constipation and urinary retention- not insignificant in the dying patient and these drugs can be expensive.
Cochrane Review: There is no evidence that any intervention, pharmacological or nonpharmacological is superior to placebo in the treatment of noisy breathing in dying patients. We acknowledge that in the face of heightened emotions when death is imminent, it is difficult for staff not to intervene- however if anticholinergics are used adverse effects such as dry mouth, urinary retention & constipation must be monitored.
Prevalence, Impact, and Treatment of Death Rattle: A Systematic Review- Lokker et al. (2014). We identified 39 articles, of which 29 reported on the prevalence of death rattle, eight on its impact, and 11 on the effectiveness of interventions. There is a wide variation in reported prevalence rates (12%â€“92%; weighted mean, 35%). Death rattle leads to distress in both relatives and professional caregivers, but its impact on patients is unclear. Different medication regimens have been studied, that is, scopolamine, glycopyrronium, hyoscine butylbromide, atropine, and/or octreotide. Only one study used a placebo group. There is no evidence that the use of any antimuscarinic drug is superior to no treatment.
Common medications with anticholinergic effects:
Morphine, oxycodone, midazolam, lorazepam, dexamethasone, prednisolone, cyclizine, levomepromazine, hyoscine, glycopyrrolate, sodium valproate, digoxin, olanzapine, frusemide