Palliative and End-of-Life Care in LTC: Evaluation and Treatment of Dyspnea, Death Rattle, and Myoclonus
- Thu, 5/20/10 - 2:29pm
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Pages 37 - 41
This article is the second in a series on palliative and end-of-life care in the LTC setting. The first article appeared in the April issue of the Journal.
The goal of palliative care is to prevent and relieve suffering for patients, regardless of their stage of illness. Most LTC patients should have palliative treatments integrated into their comprehensive care plan because of their high mortality rate and prevalent burden of suffering due to their chronic illnesses. These patients can be expected to suffer from many symptoms as their illness progresses. Three troubling symptoms that challenge LTC providers include dyspnea, death rattle, and myoclonus. Optimum care for these symptoms begins with vigilance for their occurrence with daily activities. Evaluation includes looking for precipitating or exacerbating causes, augmented by collaborative care planning with patients, families, and the interdisciplinary team. Clinicians should select appropriate pharmacological and nonpharmacological treatments, and outline a plan to monitor for beneficial and adverse effects of treatments. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[5]:37-41)
A good definition of palliative care is “whole-person care for patients whose diseases are not responsive to curative treatment,”1 whose goal is “to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies.”2
Palliative care is not only for those at or near the end of life, but also for persons living with progressive chronic conditions. Common chronic conditions encountered in long-term care (LTC) include the following: frailty; advanced stages of cardiac, pulmonary, renal, or hepatic disease; dementia; and other progressive neurological diseases.
The term hospice refers to “a program that provides coordinated comprehensive palliative care for terminally ill patients and their families.”1 The Medicare Hospice Benefit funds hospice services for those in the terminal phase of illness, but many LTC residents with palliative care needs may not meet hospice enrollment criteria or may decline hospice enrollment.
Most LTC patients will die of progressive nonmalignant diseases.3,4 Their death often follows many months of progressively distressing symptoms that accompany advanced chronic conditions.5 Thus, palliative treatments should not be reserved for those LTC patients who are actively dying. Those patients may have more intense distress or a greater number of symptoms, but clinicians should employ palliative treatments according to the patient’s needs and goals of therapy.
As chronic illnesses progress, patients commonly experience symptoms such as pain, dyspnea, anxiety, and depression.5 When they are near the end of life, expected signs and symptoms may include noisy breathing, delirium, or myoclonus.6 Most clinicians practicing in LTC provide competent evaluation and care of anxiety, depression, and delirium, so this article will focus on anticipating, recognizing, assessing, and treating dyspnea, noisy breathing, and myoclonus.
General Principles
An essential practice for good palliative care is to be vigilant for those distressing symptoms that complicate most chronic conditions. For example, 80% of patients with end-stage heart failure will have pain, 63% will die with severe dyspnea, and up to 70% will have depression.7 Patients and caregivers may not report these symptoms because they may accept them as a “normal” part of the disease that must be endured. Thus, one must actively inquire about distressing symptoms and observe patients in their activities to detect these symptoms.
Dyspnea, Death Rattle, and Myoclonus are signs that I have seen countless amounts of time. If we look at the issue of palliative care from a joint model, we can see that the CARE that we give is usually self directed.
Reply to this comment »For many the reason for their loved one to stay present is for their own desires, not the patients. We as nursing and clinical staff have seen this for years. Advanced Directives are the key here, as it gives clear concise guidelines for care under the provision of the client.
This long drawn out debate is simple and easy. But my question is to watch a person die is the most painful for everyone, especially the client/patient. Where does natural death end and compassion start...(rhetorically speaking) this is the eternal debate.
Unless the clinician has died then they cannot give a reliable guarantee that the client is under no duress. The only need for them to go on under these circumstances is for someone else's religious beliefs or self interest.
For what it is worth, my Advanced Care Planned has already been written, devised and layed out. I will go in calm and passive manner. The more the world changes, the more the acceptance of the reality of a "Soylent Green" future is more and more evident.
After experiencing my father's prolonged death rattle ( 3 days), with little help or advice from Hospice care (they seemed to retreat when death seemed imminent), I highly recommend that Hospice practitioners understand that families need to hear more than once that the rattle is more difficult to hear than to experience. My father's panic and distress, along with the horrible noise, led us to believe that he was drowning, fighting for his life. It was a terrible ending to an otherwise loving, calm passage. There has to be a better way.
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