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Clinical News Summer 2017 Nearly 2,000 butterfly folders have been distributed thanks to the collaboration of healthcare organizations making a community-wide effort to make health care wishes known. For more information about this 3090 North 12th Street, Unit B Grand Junction, CO 81506 advanced directives initiative Clinical News Summer 2017 contact HopeWest at (970) 257-2360 Noisy Breathing at the End-of-Life By Ellissa Tiller, MD, FAAHPM, CPE, VPMA HopeWest Movie deaths do not nurse friend, who was unfamiliar with prepare us for the death the dying process, was very worried that rattle. Its unfamiliar Mrs. G. was suffering and ultimately noise scares us and demanded that the patient receive IV HOPEWEST PHYSICIANS makes us feel helpless. atropine in a desperate attempt to stop & PROVIDERS Erin Arthur, MD Inside this Issue: It makes us worry what she thought was profound suffering. Diane Brown, MD that our loved one is This apprehension transferred to the Bryan Gieszl, MD suffering. We want it to patient’s husband and caused him to have Carol Fowler, MD Filling in the gaps in stop. We’re not ready to a prolonged grief reaction. Laura Harrison, NP Ellissa Tiller, MD, let go. Karin Lee Hughes, MD palliative care FAAHPM, CPE, VPMA Why do people have noisy breathing at K. Ellissa Tiller, MD - Page 2 - Heidi Marlin, MD Mrs. G. was in her early 60’s when the end-of-life? Our upper airway muscles Crystal Owens, MD she contracted multiple myeloma. become relaxed, causing an increase in Ona Ridgway, NP Unfortunately, chemotherapy failed and snoring-like sounds. The depth and rate of Kellie Turner, MD Noisy Breathing David West, MD at the End-of-Life transplantation was ruled out. She was our respirations change – leading to changes on a rapid downhill course. In her final in the tone or pitch of our breath. We lose the OFFICE LOCATIONS When Breath Becomes Air: - Page 3 - days, as she lay there unconscious, she ability to swallow our normal oral and throat Grand Valley developed a pronounced harsh noise secretions, causing a gurgling-like noise in 2754 Compass Drive #377 Inside A Doctor’s Mind At The End of His Life Grand Junction, CO 81506 When Breath with every respiration. Mrs. G. did not the back of our throats. As 36 year-old, Dr. Paul Kalanithi was on the verge of Becomes Air grimace or become restless. She was Noisy Breathing at the End-of-Life Administrative Offices started on various drying agents. Her 3090 N. 12th Street, Unit B completing his residency in neurosurgery, a CT scan lead - Page 4 - continued on page 2 Grand Junction, CO 81506 to the diagnosis of stage IV lung cancer. This soon-to-be Phone (970) 241-2212 neurosurgeon and father suddenly went from treating Fax (970) 257-2400 Education Recap: When Grief is Complicated patients to becoming one. Plateau Valley & DeBeque Thank you to all who joined HopeWest and P.O. Box 294 When Breath Becomes Air is an account of Dr. Kalanithi’s Martin Mortuary for the teleconference, Collbran, CO 81624 Living with Grief: When Grief is Complicated. Phone (970) 487-3844 transformation from a naïve medical student to a doctor Fax (970) 487-3422 with terminal illness. Written in the last two years of his This professional education opportunity was held in April, at the HopeWest Hospice Care Delta County life, Kalanithi confronted his own mortality while trying to 195 Stafford Lane answer the difficult questions many patients face at the Center. Delta, CO 81416 Phone (970) 874-6823 end-of-life. During this presentation area healthcare Fax (970) 874-6903 workers, educators, social workers, When Breath Becomes Air was named one of the best books of the year by the Montrose & Ouray Counties counselors, clergy, funeral directors and 725 South 4th Street Washington Post, The New York Times and NPR. other professionals learned how to improve Montrose, CO 81401 their ability to support people facing serious Phone (970) 240-7734 Fax (970) 240-7263 “One of the most poignant things about Dr. Kalanithi’s story is that he had grief. This seminar hosted by the Hospice postponed learning how to live while pursuing his career in neurosurgery. Foundation of America focused exclusively Meeker 575 3rd Street By the time he was ready to enjoy a life outside the operating room, what he For more upcoming educational on addressing risk factors, assessments, Meeker, CO 81641 needed to learn was how to die,” wrote Janet Maslin, The New York Times. opportunities at HopeWest visit danger signs and current treatments. Phone (970) 878-9383 HopeWestCO.org. Education Recap continued on page 2 2 • Clinical News Clinical News • 3 Filling in the Gaps in Palliative Care Noisy Breathing at the End-of-Life by Nancy Lofholm Continued from page 1 Featured in the National Hospice and Palliative Care Organization’s spring publication of the Newsline The prevalence of the death rattle varies widely, Do anti-secretory medications help? Probably not. They she organized would grow and expand services to become depending on the definition – from 12 to 92% of patients. don’t help with noisy breathing secondary to relaxation a respected model for creative and effective palliative Three quarters of patients die within 48 hours of onset. of airway musculature or changes in respiratory patterns. care. Through trial and error and leaps of faith – with a It tends to fluctuate and diminish as someone gets closer A large trial showed no difference between drying agents cadre of committed volunteers and inventive financing to death. Surprisingly, there is no association between IV (atropine, hyoscine and scopolamine). A more recent – HopeWest was able to create a continuum of care fluids and the development of trial showed no difference between that operates successfully beyond the confines of the the death rattle. sublingual atropine and placebo. So, healthcare and insurance industries. if they are not helpful, are they at What effect does it have on least benign? Unfortunately, these . Whitney said she sees all that as validation that the dying person? There is no anticholinergic agents can cause a palliative care is a valuable safety net for the healthcare difference in distress in patients severely dry mouth, confusion and system. It is an impetus for establishing a more seamless with or without the death rattle. hallucinations, as well as urinary system of delivering palliative care nationwide. Most patient are unresponsive retention and constipation. Nearly 40 years ago, when Christy Whitney was organizing in the last 48 hours of life and an all-volunteer hospice in the small Colorado mountain She hopes more hospice organizations will take the same are presumably unaware. Mrs. G’s noisy respirations were town of Durango, she was struggling with a word, and with mostly related to her history of sleep philanthropic view HopeWest has embraced – a mission However, about half of families a void. The term “palliative care” hadn’t yet entered the apnea and snoring, which worsened as that it carries out and refines every day. It hasn’t been and caregivers find the death rattle distressing – they worry lexicon as the designation for what would eventually be her muscles relaxed and her breathing changed. Drying easy. It hasn’t been without stumbles. But it has proven that it is causing suffering, and it a stark reminder them a range of services encircling hospice care. And ill people agents were not going to help and the focus on these that gaps can be filled. It has shown a way forward for that they are about to lose their loved one. Some family were falling through cracks in the fledgling hospice system: medications as the only solution probably worsened the delivering the expanded care that didn’t even have a members, on the other hand, find it reassuring as a useful There was a gap between those who qualified for hospice anxiety for the family. name when Whitney entered the hospice field. Whitney’s sign of imminent death. because they were close to dying, and those with serious overarching advice for other hospices who want to join So, what do we do? We talk with families and prepare illness who needed care at a lesser level. this mission is daringly simple: “Decide what you want to So, what can we do to help? First and foremost, education, them. We discuss what to expect and reassure them. Soft do. And jump off that cliff.” normalization and reassurance. We need to discuss with music. Repositioning. If drying agents are tried in patients Those issues were still conundrums in 1993 when families that it is likely to occur and unlikely to cause any with very wet upper airway secretions, there needs to be Whitney moved on to Grand Junction, CO and became To read the full NHPCO feature visit HopeWestCO.org. discomfort for the patient. Repositioning patients on their a low threshold for stopping them. The suffering we need the founding CEO of HopeWest. The non-profit hospice Visit the “about us” section and click on the “news” tab. side or even in the lateral Trendelenberg position can help to focus on is that of the family and caregivers. Our calm mobilize secretions and let them drain out of the patient’s reassurance and support is what is needed most. mouth. Lateral positioning also reduces snoring. White noise or soft music can help take family members’ minds Education Recap: When Grief is Complicated off the sound. Continued from page 1 The seminar introduced instances when grief becomes distortion of an individual’s successful undertaking of one or • Circumstantial factors – including traumatic and sudden well-being should be considered.
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