Dying Patients

Introduction

Understanding the care of dying patients is crucial for Canadian medical practitioners and a key component of MCCQE1 preparation. This guide focuses on the unique aspects of end-of-life care in the Canadian healthcare system, aligning with the CanMEDS framework and MCCQE1 objectives.

Key Concepts in End-of-Life Care

Palliative Care vs. Hospice Care

The Canadian Perspective

In Canada, palliative care is an essential component of the healthcare system, with a focus on:

1. Universal access to palliative care services
2. Integration of palliative care into all healthcare settings
3. Emphasis on patient and family-centered care
4. Cultural sensitivity and respect for diverse beliefs

Signs and Symptoms of Approaching Death

Recognizing the signs of imminent death is crucial for providing appropriate care and support. Common signs include:

• Decreased level of consciousness
• Changes in breathing patterns (e.g., Cheyne-Stokes respiration)
• Mottling of the skin (livedo reticularis)
• Decreased urine output
• Loss of ability to swallow

Management of Common Symptoms in Dying Patients

Ethical Considerations in End-of-Life Care

Canadian healthcare providers must be aware of key ethical principles and legal considerations:

1. Autonomy: Respect patient's wishes and advance directives
2. Beneficence: Act in the patient's best interest
3. Non-maleficence: Avoid causing harm (e.g., unnecessary interventions)
4. Justice: Ensure fair allocation of resources

Medical Assistance in Dying (MAiD)

MAiD is legal in Canada under specific circumstances. Key points for MCCQE1:

• Patient must be eligible for Canadian healthcare services
• Must have a grievous and irremediable medical condition
• Must be capable of making healthcare decisions
• Must provide informed consent

Communication with Patients and Families

Effective communication is a core competency in the CanMEDS framework. When dealing with dying patients:

• Use clear, compassionate language
• Avoid medical jargon
• Address cultural and spiritual needs
• Involve family members as appropriate
• Discuss goals of care and treatment preferences

Canadian Guidelines for End-of-Life Care

The Canadian Hospice Palliative Care Association (CHPCA) provides guidelines for end-of-life care. Key recommendations include:

1. Early integration of palliative care
2. Regular assessment of patient and family needs
3. Interdisciplinary team approach
4. Continuity of care across different settings
5. Bereavement support for families

Key Points to Remember for MCCQE1

• Understand the difference between palliative care and hospice care in the Canadian context
• Recognize signs and symptoms of approaching death
• Know how to manage common end-of-life symptoms
• Be familiar with ethical considerations, including MAiD legislation in Canada
• Understand the importance of effective communication with patients and families
• Know the key points of the CHPCA guidelines for end-of-life care

Sample Question

A 78-year-old woman with advanced ovarian cancer is admitted to the palliative care unit. She has been experiencing increasing pain and dyspnea over the past week. Her current medications include hydromorphone 2 mg orally every 4 hours as needed for pain. On examination, she appears uncomfortable and is using accessory muscles to breathe. Her respiratory rate is 28 breaths per minute, and oxygen saturation is 92% on room air. Which one of the following is the most appropriate next step in management?

• A. Increase the dose of oral hydromorphone
• B. Start oxygen therapy via nasal cannula
• C. Administer subcutaneous hydromorphone
• D. Initiate non-invasive positive pressure ventilation
• E. Prescribe oral lorazepam for anxiety

Explanation

The correct answer is:

• C. Administer subcutaneous hydromorphone

Explanation: In this scenario, the patient is experiencing increased pain and dyspnea, which are common symptoms in end-of-life care. The most appropriate next step is to administer subcutaneous hydromorphone. This route of administration is preferred in palliative care when oral medications are insufficient or when rapid pain control is needed. Subcutaneous administration provides faster onset of action compared to oral medication and can help manage both pain and dyspnea.

Option A (increasing oral hydromorphone) is less appropriate as the patient is already uncomfortable, and oral medication may not provide quick enough relief. Option B (oxygen therapy) may provide some comfort but does not address the underlying pain and is not the primary intervention needed. Option D (non-invasive ventilation) is overly aggressive for a palliative care patient and may cause discomfort. Option E (oral lorazepam) does not directly address the primary symptoms of pain and dyspnea.

This question tests the candidate's knowledge of symptom management in palliative care, which is an important aspect of end-of-life care in the Canadian healthcare system and a key topic for the MCCQE1 exam.

References

1. Canadian Hospice Palliative Care Association. (2013). A Model to Guide Hospice Palliative Care. Ottawa, ON: CHPCA.

2. Harlos, M., et al. (2017). Dying patient in the ICU: FMEA approach to developing a guide for end-of-life care. BMJ Quality & Safety, 26(9), 721-729.

3. Government of Canada. (2021). Medical assistance in dying. Retrieved from https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html (opens in a new tab)

4. Zimmermann, C., et al. (2014). Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet, 383(9930), 1721-1730.

5. Canadian Medical Association. (2017). CMA Policy: Palliative Care. Ottawa, ON: CMA.