Treating the symptoms should be determined if possible according to their etiology. For example, a vomiting is treated as part of hypercalcemia other than a vomiting due to increased intracranial pressure. However, the diagnosis of symptom causes undue effort can be the result if the tests are stressful or risky or a specific therapy, for. As major surgery, has been excluded before. In the dying supportive interventions including a non-specific treatment or shortly consecutive empirical treatment trials are often better for the patient as a comprehensive diagnostic evaluation.
Physical, mental, emotional and spiritual needs are common among patients with fatal disease, and patients often worry about tedious and un decreased suffering. Physicians can reassure patients that the distressing symptoms can often be anticipated and prevented, and if can be treated there. Treating the symptoms should be determined if possible according to their etiology. For example, a vomiting is treated as part of hypercalcemia other than a vomiting due to increased intracranial pressure. However, the diagnosis of symptom causes undue effort can be the result if the tests are stressful or risky or a specific therapy, for. As major surgery, has been excluded before. In the dying supportive interventions including a non-specific treatment or shortly consecutive empirical treatment trials are often better for the patient as a comprehensive diagnostic evaluation. As a symptom of a number of reasons, and may respond differently to treatment with increasing impairment of the patient, the treatment must be closely monitored and reviewed over and over again. A Medikamentenüber- or -unterdosierung is dangerous and must be avoided that metabolism and clearance change due to a deteriorating overall situation in the light. If the expected survival time is short, the degree of symptom severity dictates the initial treatment. Pain Approximately half of the patients who die from cancer, has a lot of pain, but only half of them experiences a reliable pain relief. Many dying with failure of organ systems or dementia have severe pain. Sometimes pain could be controlled per se, but continue, because the patients themselves, relatives and doctors a false idea of ??pain and the drugs (especially opioids) have that could suppress it. The result is a significant and persistent underdosing. Patients taking pain differently true, depending on whether other factors are present (eg. As fatigue, sleep disturbance, anxiety, depression, nausea). The choice of analgesic depends largely on pain intensity and cause of, which can be revealed only by a discussion with the patient and his observation. about patients and doctors need to be aware that any pain can be alleviated by an adequate medication in sufficient dosage, although this may be caused sedation or mental confusion. Most aspirin, acetaminophen or NSAIDs are used for mild pain, or oxycodone for moderate pain and hydromorphone, morphine or fentanyl for severe pain (pain treatment). When dying patients oral opioid therapy is convenient and inexpensive. Sublingual administration is particularly pleasant because the patients do not have to swallow. Long-acting opioids are best suited for long-lasting pain. Doctors should prescribe opioids at appropriate dosages and on an ongoing basis and make additional short-acting opioids for breakthrough pain available. Unfounded fears on the part of the public or the medical staff regarding a dependence put the use of opioids unfortunately often limits. With continuous use, although a pharmacological dependence can occur, but in dying patients – apart from an unwanted withdrawal – not a problem. Behaviors such as in addicts are rare and usually well controlled. In the unusual event that opioids are not given orally or sublingual, they may rectally, i.m., i.v. or s.c. are given. The side effects of opioids include nausea, sedation, confusion, constipation and respiratory depression. Opioid-induced constipation should prophylactically (symptom relief for the dying patient: constipation) are treated. The patients develop significant habituation to the respiratory depressant and sedative effects of morphine are generally, but much less develop tolerance to the analgesic and constipating effect. Opioids may also Myokloni, to an agitated delirium cause hyperalgesia and cramps. These neurotoxic side effects may result from an accumulation of toxic metabolites and usually go back then, if another opioid is used. If they experience these side effects and in severe pain or palliative pain specialists should be consulted. Is the administration of an opioid in a constant dosage is no longer sufficient, increasing to 1.5 to 2 times the previous dose (B. calculation based on the daily dose z.) May be indicated. In general, no respiratory depression occurs, if the new dosage is not increased to more than twice the previously tolerated dose. The use of related substances for pain relief improves mood and makes it often, the opioid dose, thereby reducing their side effects. Corticosteroids can reduce the pain associated with inflammation and swelling. Tricyclic antidepressants such as nortriptyline, and doxepin support the treatment of neuropathic pain (neuropathic pain); Doxepin leads in addition to sedation. Oral gabapentin at doses of 300-1200 mg 3 times a day can relieve neuropathic pain. Methadone is useful in refractory or neuropathic pain; However, its kinetics is not constant, which is why it needs to be monitored closely. Benzodiazepines have proven in patients as low, their pain is exacerbated by a feeling of fear. In severe localized pain nerve blockage can cause a relief in just a few side effects by a physician experienced in the treatment of pain anesthesiologist. Different techniques of nerve block can be used. For continuous infusion of analgesics, often in combination with an anesthetic, epidural or intrathecal indwelling catheter be placed. In some patients, help pain modulation techniques such. B. Guided Affective Imagery, hypnosis, acupuncture and relaxation (mental and physical strategies (relaxation techniques)). Advice on stress and anxiety can be as helpful as spiritual support from a chaplain. Dyspnea Shortness of breath is one of the most feared symptoms and makes the dying man probably most afraid. The main causes of respiratory distress are heart and lung diseases. Other factors include severe anemia and chest wall or abdominal diseases, the painful respiratory cause (z. B. rib fracture) or breathing (z. B. massive ascites) interfere. Metabolic acidosis caused tachypnea, but no feeling of breathlessness. Anxiety (sometimes due to delirium or pain) can cause tachypnea with or without sensation of breathlessness. Reversible causes should be treated specifically. For example, offers a chest tube in a tension pneumothorax or draining of pleural effusion a quick and definitive relief. Supplementales O2 can sometimes correct hypoxemia. Atomized albuterol and oral or injectable corticosteroids may help in the bronchospasm and inflammation of the bronchi. If death but is imminent or definitive treatment for the cause of shortness of breath is not available, the correct symptomatic treatment can improve the condition of the patient regardless of the cause. If death is expected and goal of care is focused on convenience, then pulse oximetry BGA, ECG and imaging can not be displayed. Doctors should use general comfort-oriented treatments, including positioning (z. B. sitting), increased air movement with a fan or open windows and night relaxation techniques. Opioids are the treatment of choice for dyspnea shortly before dying morphine can sublingual or 2 to 4 mg in a low dosage of 2-10 mg s.c. every 2 h, the shortness of breath in patients who have not received any opioids, relieve. Morphine can weaken the central response to an increase in CO2 or O2 waste, thereby reducing dyspnea and anxiety without causing significant respiratory depression. When patients are receiving opioids for pain, the doses that relieve shortness of breath, often more than twice the usual. Benzodiazepines often alleviate anxiety in respiratory distress and fear of a return of dyspnea. O2 can also give psychological convenience for patients and family members offer, even if it is not corrected hypoxemia. Patients prefer O2 usually through a nasal cannula. An O2-face mask can increase agitation of a dying patient. For the treatment of patients with viscous secretion nebulized saline solution can be used. The death rattle is noisy breathing caused by air movement over bundled secretions in the mouth and throat and bronchi and often to death in hours or days. suggesting. The death rattle is not a sign of discomfort when the dying patient, but may interfere with family members and caregivers. To minimize the death rattle, nurses should drink of the patient limit (eg., Orally, iv, enteral) and position it on the page or semi-prone position. Oropharyngeal aspiration is usually not effective to achieve the bundled secretions and can cause discomfort. A congestion of the respiratory tract is best treated with an anticholinergic such as scopolamine, atropine, glycopyrrolate, or (z. B. glycopyrrolate with 0.2 mg sc every 4 to 6 hours, or 0.2 to 0.4 mg PO every 8 hours, with increasing the dose as required). Adverse reactions usually occur with repeated doses and include blurred vision, sedation, delirium, tachycardia, hallucinations, constipation and urinary retention. Glycopyrrolate does not cross the blood-brain barrier, leading to less neurotoxic side effects than other anticholinergic drugs. Anorexia often experience an anorexia and a significant weight loss in the dying. The family members can be very difficult to accept the low food intake of the patient often because this means for them to accept the death of the patient. Patients should as much as possible their favorite foods are offered. Some conditions that bring a decreased food intake with it can be easily treated – as such. As gastritis, constipation, toothache, oral candidiasis, pain, nausea – and neither should you. Some patients benefit from appetizers such. B. corticosteroids (dexamethasone 2-8 mg p.o. 2 times daily or prednisone, 10-30 mg / day p.o.) or megestrol p.o. 160-480 mg 1 times a day. However, if the patient’s death is imminent, the members should be advised that neither diet nor fluid administration are necessary to preserve the well-being of the patient. I.v. Fluid resuscitation, TPE (total parenteral nutrition) and enteral nutrition through a tube does not extend the life of dying Direction patients the discomfort of the patient seem rather to reinforce and accelerate death. Negative effects of artificial feeding for dying patients may be pulmonary congestion, pneumonia, edema and pain associated with inflammation. go Conversely, dehydration and ketosis in the wake of reduced caloric intake with an analgesic effect and the absence of discomfort associated. The only known, caused by dehydration impairment in proximity to death is xerostomia, which can be prevented by mouth swab or pieces of ice or fixed. Even debilitated and cachectic patients can still live several weeks after all the food and almost all liquid flow was stopped. The family members should understand that the termination of hydration does not mean the patient’s immediate death and usually not speed it up. Supportive care including good oral hygiene is essential for the well-being of the patient at this stage. Nausea and vomiting Many seriously ill patients complain of nausea, often without vomiting. Nausea can occur with problems of the gastrointestinal tract such. B. constipation and gastritis, in metabolic problems such as hypercalcemia and uremia, drug side effects, increased intracranial pressure due to brain tumors or psychosocial stress. If possible, the treatment of probable cause should meet such. As a completion of the treatment with NSAID, treating gastritis with H2-blockers or proton pump inhibitors and the experimental administration of corticosteroids in patients with known or suspected brain metastases. Arises the nausea due to stomach distension and of reflux, the use of metoclopramide has (eg., 10-20 mg po or sc 4 ??times daily as needed) proved because there the gastric tone and gastric contractions while relaxation of the sphincter pylori elevated. May have a reason for nausea are found, patients may benefit from a non-specific treatment with a phenothiazine such. p.o. B. promethazine 4 times daily 25 mg, prochlorperazine 10 mg p.o. before meals orin patients who can not tolerate oral medication to himself, 2 times 25 mg daily rectally. Anticholinergics such as scopolamine and antihistamines meclizine and diphenhydramine, repeated prevent nausea in many patients. A combination of lower doses of these substances mentioned above often improves the efficiency. Among the medicaments of the 2nd choice against intractable nausea belongs haloperidol, starting with 1 mg p.o. or s.c. every 6-8 hours, then titrated up to 15 mg daily. The 5-hydroxytryptamine (5-HT) antagonists ondansetron and granisetron 3-often cause a dramatic improvement in the chemotherapy-induced nausea. However, with dying patients, they are among the drugs of second choice for complex cases of nausea, as they are quite expensive. Nausea and pain due to an intestinal passage obstruction are common in patients with a quite advanced abdominal cancer. In general, the i.v. Administration of fluids and nasogastric derivative in the hospice care is pointless. Symptoms of nausea, pain and intestinal cramps are with 0.125-0.25 mg every 4 hours hyoscyamine sublingual or s.c., topically given scopolamine (1.5 mg), rectally, or s.c. given morphine or any other of the above-mentioned anti-emetics to control. Octreotide inhibits s.c. at a dose of 150 micrograms or iv every 12 hours gastrointestinal secretion; it leads to a drastic reduction of nausea and painful stomach strain. If octreotide is given along with antiemetics, usually no more nasogastric drainage is required. Corticosteroids such. B. iv dexamethasone at a dose of 4-6 mg 3 times daily, i.m. or rectally a stenosing inflammation may decrease in tumor area and eliminate the obstruction temporarily. Intravenous fluid replacement may increase the edema in the area of ??obstruction. Constipation constipation occurs due to inactivity, use of opioids, and drugs with anticholinergic effect and a reduced intake of fluid and fiber dying in common. To the last or the penultimate day of a regular bowel movement is in dying patients an essential part of their well-being. Laxatives help prevent fecal induration, especially when patients receiving opioids. Regular monitoring of bowel function is essential. Most patients are doing with the two-times daily regimen of a stool softener such as docusate and a mild stimulant laxative such as senna and casanthranol good. If stimulant laxatives lead to convulsive disorders, this can be possibly solved by a higher dose of docusate alone or by an osmotic laxative such as lactulose and sorbitol, starting with 15-30 ml p.o. 2 times a day and adapted depending on the effect. A soft faecal impaction can be addressed through Bisacodylzäpfchcn or a saline enema. For hard Stuhlverhalt an inlet with mineral oil can occur, possibly together with an oral benzodiazepine, z. As lorazepam, or an analgesic and subsequent digital removal. Then care should be taken in patients for the prevention of recurrence of intensive bowel care. Decubitus ulcers Many dying people are immobile, malnourished, incontinent, and cachectic and thus susceptible to pressure ulcers (decubitus ulcers). Prevention includes the pressure reduction by repositioning the patient every 2 hours; it can be used a special mattress or continuously ventilated air cushion bed. Incontinent patients should be kept as dry as possible. In general, the use of an indwelling catheter, with its inconvenience and the risk of infection is only justified if the beds causes pain or members specifically request it. Delirium and confusion central nervous disorders that may accompany the terminal stage of an illness, patients and relatives can be very worrying; The patients are often not aware of these disorders. Delirium is common. Reasons for this may lie metabolic and CNS disorders in medication, in hypoxia. If the cause can be found, a simple treatment may be appropriate, provided that can enter into a more meaningful communication with the family and friends to patients. Patients who feel comfortable and do not perceive their environment correctly, it can get better without treatment. If possible, physicians should find out the wishes of the patient and family and be guided thereof in the treatment. Simple reasons for delirium should be determined. Agitation and restlessness are often based on a urinary retention and can be resolved promptly by a catheterization. Confusion in debilitated patients is promoted by sleep deprivation. Agitated patients may benefit from benzodiazepines; However, benzodiazepines may give rise to confusion. Inadequate pain control can lead to insomnia or agitation. The pain is adequately treated, sedation for night out can help. Members and visitors can help to reduce confusion by frequently touching the patient’s hand and repeatedly tell him where he is and what’s going on. Patients with severe terminal agitation, which does not respond to other measures sometimes respond best to barbiturates; the members should know that patients do not usually wake up after the use of such substances. Pentobarbital as a short-acting barbiturate Rasch and can in doses of 100-200 mg i.m. be given every 4 hours as needed. Phenobarbital, which is longer acting, can p.o., s.c. or rectally. Often, midazolam, a short-acting benzodiazepine effect. Depression and suicide Most dying have depressive symptoms. The best course of action in these cases is to give the patient psychological support and to enable him to express his concerns and feelings. An experienced social worker, doctor, nurse or chaplain can assist with these concerns. The experimental administration of an antidepressant should be exercised in patients often develop a persistent, clinically significant depression. Selective serotonin reuptake inhibitors (SSRI) can be used in patients who live longer than four weeks in all probability, which are necessary to achieve antidepressant effect. Depressed patients with anxiety and sleep disorder benefit from the sedative effect of a given for the night tricyclic antidepressant. Patients in withdrawal or with a vegetative symptoms (Vegetative and minimally conscious state: symptoms and complaints) may p.o. with methylphenidate at a dose of 2.5 mg be started once a day and increased as needed to 2.5-5 mg 2 times daily for breakfast and lunch. Methylphenidate at the same dosage can be used to bring about an energy increase in patients who are fatigued because of analgesics or somnolent, for a few days or weeks. Methylphenidate strikes quickly, but can cause agitation. Because the duration of action is short, and the side effects are only briefly. Suicide Serious medical condition is a major risk factor. Other risk factors for suicide are common in patients who are sick enough to die; these include advanced age, male gender, psychiatric comorbidity, an AIDS diagnosis and uncontrolled pain. In cancer patients, the incidence of suicide is almost twice as high as in the general population, and patients with lung, stomach, and head and neck cancer have the highest suicide rates among all patients with cancer. Doctors should routinely examine seriously ill patients to depression and suicidal thoughts. Psychiatrists should urgently all patients who are seriously at risk of hurting themselves or have to investigate serious suicidal thoughts. Stress and grief Some people approach death in peace, but most people and families have onerous phases. Dying is particularly connected to loads when interpersonal conflict patients and prevent them from spending their last moments together in peace with one another. Such conflicts can lead to an exaggerated sense of guilt or an inability to mourn with the survivors, in patients fear may arise. A national who supplied the dying at home can feel physical and emotional stress. Most such stress in patients and is best treated by compassion, information, advice and sometimes a brief psychotherapy. Social services can sometimes help the nurses the load. Sedatives should be used sparingly and for a short time. If the partner dies, the more survivors may be overwhelmed by the need to make decisions of legal or financial or financial management. For older couples death of one partner can bring to light a cognitive deficit of the survivors, which has so far been offset by the deceased partner. Physicians should recognize such high-risk situations, so that resources can be mobilized to prevent undue suffering and wrongdoing. Grief Grieving is a normal process that usually begins before an expected death. For the patient himself the grief often begins with a denial, which is due to the fear of loss of control, separation, suffering, an uncertain future and the loss of one’s self. Previously it was believed that the stages of mourning occur in a fixed order: denial, anger, bargaining, depression and acceptance. In truth, the stages that pass through the patient may overlap or occur in a different order, depending on the individual personality. The members of the treatment team can help the patient to accept his prognosis by listening to him and help to realize that it can determine a considerable part of his life even further by declaring him as the disease progress and as death enter and you will be assured him that the physical symptoms are manageable. If the grief is still very difficult or causes psychosis or suicidal thoughts, or if the patient has a prior serious mental disorder, a professional investigation and grief counseling may be helpful. Family members may also need support to be able to express their grief expressed. Each member of the team that knows the patient and his family may accompany them through this process and possibly provide them with professional help. Doctors and other station members must develop controlled procedures ensure the continuous care of the bereaved families.