Mrs Georges has a long history of peripheral vascular disease.  Her other co-morbidities include Diabetes Mellitus type II, ischaemic heart disease,
and chronic renal failure. One of the care staff noticed that Mrs Georges’ foot was blue and cold. She reported this to the RN. After speaking with the GP,
the RN arranged for Mrs Georges to be transferred to the emergency department of a major hospital.  She was assessed by the vascular surgical team
who advised that the only surgical option would be a below knee amputation. However, the team felt that this would be a high risk procedure due to
Mrs Georges’ co-morbidities.

A family meeting was held where Mrs Georges’ son and daughter were present.  Mrs Georges was adamant that she did not want an amputation.
She understood that her condition was likely to deteriorate.  Mrs Georges has never had an advance care directive as she prefers to ‘take things as they come’.
In the meeting, however, she expressed a wish for her life not to be prolonged.

While an inpatient she deteriorated clinically.  She developed high fevers and became unrousable.

Questions:

1. When you go to assess Mrs Georges, what aspects of her recent deterioration and current status will assist the team to identify that she may dying?

It is a clinically challenging task to confirm the correct diagnosis of dying with absolute certainty (Kennedy et al., 2014).The dying process is recognized by patterns of physical function decline, often being the first indication that the patient is entering the terminal phase of the disease process (Gauthier 2005).

2. The team have recognised that Mrs Georges is now in the terminal phase of her illness.   She has developed high fevers.  Is there a role for antibiotics?

Patients in the final stage of an advanced illness often face challenging decisions about the direction of their overall medical care and treatment of specific complications that occur as the end of life approaches. Infections and febrile episodes are among the most common acute complications experienced by terminally ill patients (Juthani-Mehta, Malani & Mitchell, 2015).

Close to 90% of hospitalized patients with advanced cancer receive antimicrobials during the week prior to death (Thompson, Silveira, Vitale & Malani, 2012) furthermore 42% of nursing home residents with advanced dementia are prescribed antimicrobials during the last 2 weeks of life (D’Agata, 2008) Approximately one-quarter of hospice recipients, for whom the intended goal of care is comfort, receive antimicrobials during the final weeks of life (Albrecht, McGregor, Fromme, Bearden & Furuno, 2013). Research suggests that antimicrobials are commonly prescribed to dying patients in the absence of adequate clinical symptoms to support a bacterial infection (Mitchell et al., 2014)

The decision of whether to prescribe antimicrobials can be challenging to address with terminally ill patients and their family members. Patients and families may incorrectly perceive antimicrobials as relatively benign and decisions about their use primarily under the purview of physicians. However, this issue should be approached using a framework of shared decision making similar to other end-of-life treatment choices.

To the extent possible, decision making about antimicrobial use should be done as part of advance care planning rather than in the moment at the time of a crisis, with treatment preferences documented in advance directives (eg, Physician/Provider Orders for Life Sustaining Treatment form). The first step is to inform patients and families that infections are expected near the end of life, and are commonly a terminal event. Individuals should understand that even if the infection were cured, the underlying illness (eg, metastatic cancer, advanced dementia) would remain.

Families and patients should also recognize what the evaluation of a suspected infection entails, and be advised about common scenarios that lead to unnecessary antimicrobial use (eg, asymptomatic bacteriuria). The risks and burdens of evaluating and treating an infection should be presented, as well as the possible benefits, while acknowledging the lack of high-quality outcome data. In addition, the option of a purely palliative approach should be described (eg, oxygen, morphine, antipyretics).

3. Mrs Georges’ son arrives and is concerned that she is not able to eat or drink. He asks, ‘Is my mother starving to death? Is she uncomfortable because she is not drinking? Can we give her some food and fluid in a drip?’ What would be your approach to discussing these issues with him? What can you learn from the literature regarding how to respond to these types of questions.
4. You come to review Mrs Georges’ symptoms 24 hours later and you notice she has respiratory secretions. What non-pharmacological and pharmacological strategies would you suggest; and what is the evidence that guides this?

Studies suggest secretions that accumulate in the throat leading to gurgling sounds at the end of life, commonly referred to as “death rattles” , although may be distressing to staff and family members they are unlikely to be disturbing to the dying patient  (Lokker, van Zuylen, van der Rijt & van der Heide, 2014)

Non- pharmacological interventions- include re positioning of the patients head.

Reassuring family members that it is unlikely the patient is suffering any discomfort.

Pharmacological interventions include- A trial of antimuscarinic agents such as glycoprrolate, however there is little evidence beyond clinical reports that support its effectiveness in patients with noisy breathing due to terminal respiratory secretions (Wee & Hillier, 2008)

5. What conversation would the treating team have with the family about the secretions?