Palliative care:

• It is an active and total approach to care, embracing physical, social and spiritual elements.
• It focuses on optimizing quality of life and well being of patients and families
• Components include:
  • Expert symptom management
  • Control of disease if feasible (Some malignancies although cannot be cured, but with adequate therapy patient survives for years to decades)
  • Good communication, ensuring patient that he/she will not be abandoned. Disease prognosis and treatment options must be honestly conveyed to patient/ relative.
  • Attention to psychologic, social and spiritual needs.

End of life care:

• Setting of death to be decided by patient/ relatives (Home/ hospice/ hospital)
• Cover all physical symptoms of end of life: 
  • Pain
  • Noisy/moist breathing
  • Restlessness/ agitation/ delirium
  • Urinary incontinence/ retention
  • Dyspnea
  • Nausea/ Vomiting
  • Fatigue
• Educate patient and family on dying process
• Respect goals and needs of the patient and family regarding the dying process
• Offer spiritual support and emotional support. Support culturally meaningful rituals.
• Document patient/ relatives decisions in case sheet.
• Skin safety protocol- Pressure relieving mattress/ regularly repositioning of patient
• Eye and mouth care to maintain moisture
• Treat for urinary retention/ fecal impaction
• Ensure deactivation of implanted defibrillator
• Discontinue unnecessary diagnostic tests and interventions such as anticancer therapy, transfusions, needle pricks, SpO2 monitoring, dialysis, IV  fluids and blood glucose monitoring
• Switch routes of medication administration when oral route is no longer feasible.
• Adjust the doses of medications for optimal comfort
• Morphine- for dyspnea/ pain
• Sedation if required. Midazolam- 0.4- 0.8mg/hr
• "Death rattle"- Positioning and suctioning to remove pharyngeal mucus. Hyoscine (Buscopan) to be started to prevent further mucus secretion.
• Allow the patient and family to have uninterrupted time together. Allow privacy as far as possible.
• Counsel the family on the importance of DNI/DNR and allowing natural death

After death interventions:

• Immediately after death:
  • Inform family of death and offer condolences
  • Remove tubes/ catheters and then provide family time with body
  • Ensure culturally sensitive and respectful treatment of the body
  • Fill death certificate forms
  • Inform other health care professionals involved in the treatment of patient
• Bereavement support:
  • Formally express the condolences on patient's death- card/call/letter
  • Attend a debriefing meeting with the family if they desire one

Stages experienced by close relatives after death:

• Immediate: Numb, confused, disbelief
• By 2nd month: Craving
• By 6 months: Accepting the reality and thinking about re-engaging in relationships and work