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End of Life Care
End of Life Care
Which of the following is not documented in the Physician
Orders for Life-Sustaining Treatment Paradigm (POLST) form?
A) Instructions for resuscitation B) Types of medical interventions
desired C) Designation of durable power of
attorney for health care D) Use of artificial nutrition and
hydration
Answer
• C) Designation of durable power of attorney for health care
Choose the correct criteria for eligibility for hospice care in a patient with dementia.
Lack of meaningful verbal communication (6 or fewer words)
Hospitalization for pneumonia, pyelonephritis, sepsis, or other serious complications in previous
6 moPresence of stage 3 or 4 pressure ulcers
Weight loss of ≥5% in previous 6 moTotal dependence for activities of daily living
A) 1,2,3,4 B) 1,3,4,5 C) 2,3,4,5 D) 1,2,3,5
Answer
1. Lack of meaningful verbal communication (6 or fewer words)
2. Hospitalization for pneumonia, pyelonephritis, sepsis, or other serious complications in previous 6 mo
3. Presence of stage 3 or 4 pressure ulcers
5. Total dependence for activities of daily living
• D) 1,2,3,5
Appetite stimulants may increase ________ in patients undergoing
palliative care. A) Enjoyment of eating
B) Lean body mass C) Longevity
D) A, B, and C
Answer
• A) Enjoyment of eating
Choose the correct statement about the benefits of artificial hydration
and nutrition (AHN). A) AHN can relieve dry mouth B) Percutaneous endoscopic
gastrostomy (PEG) tubes and total parenteral nutrition increase patient
comfort C) AHN may cause dyspnea from
pulmonary edema D) PEG tubes help prevent pneumonia from aspiration
Answer
• C) AHN may cause dyspnea from pulmonary edema
Constipation is the only side effect of treatment
with opioids for which the patient does not develop
tolerance. A) True B) False
Answer
• A) True
Which of the following is notuseful for the treatment
of nausea and vomiting induced by administration of
opioids in the absence of motility and distention
problems? A) Haloperidol
B) Diphenhydramine C) Scopolamine
D) Metoclopramide
Answer
• D) Metoclopramide
Both glycopyrrolate and scopolamine cross the blood-brain barrier and may cause changes in
mental status. A) True B) False
Answer
• B) False
Approximately ________ of patients at end of life
suffer from cough. A) 10% B) 25% C) 40% D) 60%
Answer
• C) 40%
Unlike ________ for treatment of opioid
induced constipation, ________ does not cause opioid withdrawal and reversal of analgesia.
A) Oral naloxone; methylnaltrexone
B) Methylnaltrexone; oral naloxone
Answer
• A) Oral naloxone; methylnaltrexone
Which of the following statements about
methylphenidate for the treatment of depression in
patients with terminal illness is(are) correct?
A) It is the fastest acting antidepressant
B) It is well tolerated in geriatric population C) A and B
D) None of the above
Answer
• C) A and B
An 80-year-old patient is on high doses of morphine to control pain
and dyspnea at the end of life. Which one of the following
medications is appropriate for constipation caused by opioids?
A. Corticosteroids. B. Naloxone (formerly Narcan).
C. Ketamine (Ketalar). D. Polyethylene glycol solution
(Miralax).
Answer
• D. Polyethylene glycol solution (Miralax).
A 78-year-old woman with terminal breast cancer has been vomiting. She
complains of feeling anxious and fearful about her rapid decline in function. Which of the following
antiemetic medications is/are most appropriate?
A. Benzodiazepines. B. Cannabinoids.
C. Antihistamines. D. Dexamethasone.
Answer
• A. Benzodiazepines. B. Cannabinoids.
An 85-year-old man with severe pneumonia is rapidly declining and
is not responding to antibiotics. Which of the following actions can
help prevent delirium? A. Keeping familiar persons at the
bedside. B. Limiting medication changes.
C. Limiting unnecessary catheterization.
D. Using wrist restraints.
Answer
• A. Keeping familiar persons at the bedside. B. Limiting medication changes. C. Limiting unnecessary catheterization.
What should the dose of the pain medication be for breakthrough pain? What % of the 24 hour dose q 1
hour?
Answer
• 10 to 20%
PALLIATIVE AND END-OF-LIFE CARE
• Approach to discussion: study of interaction between hope and desire for prognostic information among 55 patients with terminal disease;
• 4 patterns—feelings swing between totally hopeful and completely discouraged (amount of information desired depended on stage)
• scales and balance (hopeful but realistic• wanted information but not too much)• yin-yang (hope and bad news coexisted)• Redirected hope (from hope for cure to other
things, eg, survive to certain date)• ask all patients how much information they want
Advance directive• Five Wishes form—includes designation of durable power of attorney
(DPOA) for health care• Type of medical treatment desired• degree of comfort desired• desired treatment• level of information shared with loved ones• does not direct paramedics about wishes regarding code• Physician Orders for Life-Sustaining Treatment Paradigm (POLST) form• provides instructions for resuscitation• types of medical interventions• use of antibiotics• artificial nutrition and hydration• does not designate DPOA• living will registry—available in Washington• patient sends copy of documents to central database and receives card
to carry in wallet
•
The Five WishesWishes 1 and 2 are both legal documents. Once signed, they meet the legal requirements for an
advance directive in the states listed below. Wishes 3, 4 and 5 are unique to Five Wishes, in that they address matters of comfort care, spirituality, forgiveness, and final wishes.
Wish 1: The Person I Want to Make Care Decisions for Me When I Can'tThis section is an assignment of a health care agent (also called proxy, surrogate, representative or
health care power of attorney). This person makes medical decisions on your behalf if you are unable to speak for yourself.
Wish 2: The Kind of Medical Treatment I Want or Don't WantThis section is a living will--a definition of what life support treatment means to you, and when you
would and would not want it.Wish 3: How Comfortable I Want to BeThis section addresses matters of comfort care--what type of pain management you would like,
personal grooming and bathing instructions, and whether you would like to know about options for hospice care, among others.
Wish 4: How I Want People to Treat MeThis section speaks to personal matters, such as whether you would like to be at home, whether you
would like someone to pray at your bedside, among others.Wish 5: What I Want My Loved Ones to KnowThis section deals with matters of forgiveness, how you wish to be remembered and final wishes
regarding funeral or memorial plans.Signing and Witnessing RequirementsThe last portion of the document contains a section for signing the document and having it
witnessed. Some states require notarization, and are so indicated in the document.
Discussing palliative care with patients
• Timing• at time of diagnosis of life-limiting disease• if physician expects patient’s death in next 6 to 12 mo• if patient has frequent hospital admissions• if chronic disease progresses• if patient with chronic untreatable disease presents with lifethreatening event that could
allow natural death• set safe context for discussion• open with questions about patient’s goals for their experience• questions—identify stakeholders• ask about patient’s understanding of situation• sources of strength,• Hopes• Fears• past experiences with serious illness• keys to successful discussion• allowing patient and family time to speak increases patient satisfaction and helps
reduce anxiety, posttraumatic stress disorder (PTSD), and depression among family members
• Try to aim for 66/34 with patient family 66% of talking
Hospice eligibility for patients with dementia
• criteria include• total dependency for activities of daily living
(ADLs)• lack of meaningful verbal communication (6 or
fewer words)• hospitalization for pneumonia, pyelonephritis,
sepsis, or other serious complication in previous 6 mo
• stage 3 or 4 pressure ulcers• loss of 10% of body weight in previous 6 mo• patient must have any 3
Benefits of hospice:
• nurse on-call 24 hr/day• skilled hospice certified nursing
assistant (CNA)• spiritual support• Comprehensive emotional and grief
support, with special programs for children
• hospice volunteers
Anorexia• obtain history and laboratory or radiographic data (if appropriate), and perform physical examination to seek cause• if possible, treat underlying cause (eg, reflux, constipation)• appetite stimulants—options• alcohol,• Steroids• Megestrol• delta-9-tetrahydrocannabinol,• Androgens• do not increase lean body mass or longevity• may provide patients with enjoyment of eating• Artificial hydration and nutrition (AHN)• ask about patient’s goals• during nutritional deficiency• central nervous system endorphins may cause mild euphoria• intravenous (IV) fluids do not relieve dry mouth• Percutaneous endoscopic gastrostomy (PEG) tubes and total parenteral nutrition (TPN) do not prolong life• may increase suffering (eg, dyspnea from pulmonary edema or ascites• pneumonia from aspiration• discomfort from tube or IV• possible need for restraints in patients with dementia, loose stools)• appropriate for patients with malignancies of head and neck or upper gastrointestinal tract who are having definitive
surgery or receiving radiation or chemotherapy• selected ambulatory patients (eg,• patients with HIV)• patients with amyotrophic lateral sclerosis (ALS)• for patients with dementia, tube feeding does not prolong survival, prevent aspiration, Improve pressure ulcers, improve
function, or give comfort
Anorexia
• Study results• not randomized• median survival of 59 days among 23 patients
who received PEG• 60 days among 18 patients who did not • Family concerns: encourage alternative activities
to show care for patient• in case of conflicting wishes, perform therapeutic
trial of feeding tube for specific time (eg, 3 days)• Reassess• continue only if pre-agreed goals met
Questions and answers• Letter of condolence: difficult but appreciated by family• Questions and answers: why does POLST form have full resuscitation option? • allows patient to specify wishes for other measures, eg, AHN• also, documentation of wish for resuscitation on POLST form indicates that
patient has discussed their wishes for this option• can duration of hospice exceed 6 mo? • yes; most groups follow Medicare guidelines, which require that attending
physician expects patient’s death within 6 mo• patient’s condition re-evaluated at 90 days after admission and every 60 days
thereafter• patient may remain in hospice as long as expectation of death within 6 mo
remains after these evaluations• some insurance companies pay only for specific period• many hospices provide charity care afterwards• do gastroenterologists believe that PEG tubes prevent aspiration?• literature does not support conclusion that PEG tubes that end in stomach
prevent aspiration• Tubes that terminate in jejunum may prevent aspiration
Letter of condolence• The benefit of writing a letter of condolence as twofold: to be a source of comfort to the
survivors and to help clinicians achieve a sense of closure about the death of their patient. In the sidebar on the previous page, Dr Mark Geliebter, Martinez, CA, describes how he began writing letters of condolence to his patients and the value this practice has had for him.
• If you decide that writing a letter of condolence is a practice you would like to begin incorporating into your medical practice, the following guidelines, adapted from Wolfson and Menkin's "Writing a condolence letter,"3 may be helpful.
• Address the family member. Dear Mrs Wagner, ...• Acknowledge the loss and name the deceased. Dr Murphy and I were deeply saddened
today when we learned from your hospice nurse Lois that your mother, Ruth Smith, had died.
• Express your sympathy. We are thinking of you and send our heartfelt condolences.• Note special qualities of the deceased. It seems like only yesterday that Ruth talked
about her love of card playing. I admired her energy and quick wit.• Note special qualities of the family member. I was deeply moved by the devotion you
and your family showed during the period of Ruth's final illness. Your concern was one indication of your love for her. Although she was a fiercely independent woman, I know she appreciated your involvement and help.
• End with a word or phrase of sympathy. With affection and deep sympathy, we hope that your fond memories of Ruth will give you comfort.
Doctors and Sympathy CardsBy Mark Geliebter, MD
• As soon as the Code Blue ends in the emergency department all of the housestaff scatter. During my training, I was always struck by how quickly the doctors would leave the scene as soon as the patient was pronounced dead. There was no lingering--as if no one wanted to stay in the room with the dead person. The strategy seemed to be to create physical distance from any associated feelings of failure as a doctor. There was no ritual to follow at the end of an unsuccessful resuscitation effort. There was never any discussion about the ritual of death. We would spend weeks and weeks discussing the Krebs molecular "life cycle" in medical school. However, discussions about the natural cycle of life and death were rare. After practicing internal medicine for many years at Martinez, CA, I was struck by my own lack of closure when my patients died. I too would not hover at the bedside when a patient of mine had died. I would not routinely connect with family members after a death. Many years ago, I became involved in physician wellness efforts at my facility and regionally. I realized that exploring our own relationship with death and dying was a key element in physician well-being.
• One of the outcomes of that exploration was the decision to start a new practice for myself in 1995. I began to list the name of every patient of mine who died. I generally would include a diagnosis, medical record number, date and place of death. I started a folder labeled "Death and Dying." I also began to send a sympathy card to each family (I later found these cards available as a KP stock item!).
• Initially, I began with brief statements of sympathy. More recently, I've been writing more personal comments, especially when I've had a longer relationship with the person or their family. I frequently mention that I felt privileged to have been their physician. I also try to call the families that I feel connected to. I have received frequent positive feedback from families for my personal note or call. They are most appreciative of my thoughtful acknowledgments.
• This has created a ritual practice for myself at the time of a patient's death. It also gives me a way to remember my patients. When I review my list, I can usually remember something about them, their faces, their personalities, or some ethical or medical issues that may have been challenging. Even after many years, the list elicits those memories. I would have totally forgotten many patients that had died if it weren't for my list. At times, it reminds me of memorial plaques on some synagogue or other walls that list names of members or their families who have died. Sending the sympathy card and making the follow-up phone calls have become part of my own sense of responsibility as a physician. It helps obviate the need to run out of the room after an unsuccessful Code Blue, as I did when a medical student. Integrating the reality of death; embracing it as a natural process; developing coping strategies; not labeling death as failure; finding rituals; doing outreach during and after the dying process are all part of our role as physicians. All of these insights and rituals will add to our own personal wisdom of dealing with the inevitability of our patients' and our own deaths.
Example Condolence Letter
• Below is an example of a condolence letter using the seven components above:• Dear_____________,1. Acknowledge the loss, refer to deceased by name.
I was deeply saddened to hear about the death of _____________.• 2. Express your sympathy.
I know how difficult this must be for you. You are in my thoughts and prayers.
• 3. Note special qualities of the deceased. ____________was such a kind, gentle soul. She would do anything to help someone in need.
• 4. Include your favorite memory.I remember one time_________________.
• 5. Remind the bereaved of their personal strengths and qualities.I know how much you will miss_______________. I encourage you to draw on your strength and the strength of your family. You could use your special talent of scrapbooking to make a lasting memory book of _________________.
• 6. Offer specific help.I can come over on Tuesday evenings to help you make your scrapbook. I have some lovely pictures of _______________ I’d love to share.
• 7. End the letter with a thoughtful closing.May God bless you and your family during this time and always,
• Sign your name_____________________• Keep in mind that this is only an example. Write from your heart and whatever elements you include
will be the right ones.• The next page includes information on writing a shorter version of the condolence letter: The
Condolence Note.
Condolence note• You may decide to write a shorter version of a condolence letter on note
card or on a small piece of stationary tucked inside a commercial card. If I am close enough to the deceased to have photos of them, I especially like to print one of my favorite photos on a card. That can be done from your computer or from a picture program in your local photo developing shop.
• When writing a condolence note, pick just a few elements from the example on the first page of this article. Using components #1, 2, 3, and 7 is a good guide.
1. Acknowledge the loss and refer to the deceased by name.2. Express your sympathy.3. Note any special qualities of the deceased that come to mind.4. End the letter with a thoughtful word, a hope, a wish, or expression of
sympathy e.g. "You are in my thoughts" or “Wishing you God’s peace.” Closing such as "Sincerely," "love," or "fondly," aren’t quite as personal.
• Remember that this is just a guide. You can use any of the components of a condolence letter in your note or none at all. The most important thing is to write from your heart
A letter by Abraham Lincoln• Archival communications abound with outstanding
examples of fine letters of condolence. A letter by Abraham Lincoln to a girl whose father had died in the Civil War showed several of the qualities outlined above8
:It is with deep grief that I learn of the death of your kind and brave Father; and especially that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young it comes with bitterest agony, because it takes them unawares. The older have learned ever to expect it.
• Note that Lincoln uses the word death directly and describes her father as kind and brave. Years later, one can only imagine how this woman might cherish such kind and comforting words from our sixteenth President.
A Dying Art?The Doctor’s Letter of Condolence
Gregory C. Kane, MD, FCCP
• In their commentary on writing letters of condolence, Bedell et al5 outlined why doctors do not regularly write letters of condolence. Potential explanations included a lack of time, a loss for the appropriate expression of sympathy, a feeling that they did not know the patient well enough, lack of a specific team member responsible for writing the letter, or a sense of failure over the death. No doubt, this has been fostered by a lack of role modeling or broader discussion of such practices.
• In a personal and memorable patient encounter, I sat and listened while a tearful patient cried at having received no contact from the physician who treated her husband for metastatic lung cancer for a treatment duration of 9 months. As I struggled to comprehend her sense of pain and abandonment, I considered offering as possible explanation that the physician may not have been “on call” at the time of the death and may have mistakenly believed that his partner had offered such a gesture verbally. Before I could respond, however, my patient added that her veterinarian had sent a card when the family dog died. I was speechless.
• Other physicians have shared similar experiences, sometimes involving family members, friends, or mutual patients. In his convocation speech on becoming President of the American College of Chest Physicians in 2003, Dr. Richard Irwin described a vision for patient-centered care. His vision was comprehensive but also included a discussion of sympathy cards after the death of a patient. He noted, “when physicians do not acknowledge the deaths of their patients, it is perceived that physicians are silently saying that the deceased patient was not important.
Nausea and vomiting (NV)• consider possible causes
• Opioids: act on chemotactic trigger zone (rich in dopaminergic receptors) and on vestibular system (may manifest after changing position)
• data unclear whether NV side effects similar for all opioids• patients eventually become tolerant• constipation only side effect of opioids for which no tolerance develops• if NV mild, continue drug until tolerance develops• if NV severe, rotate to other opioids• Antiemetics haloperidol, scopolamine (anticholinergic) or promethazine
(Phenergan); antihistamine diphenhydramine (Benadryl) also works well• 5HT3 antagonists (eg, ondansetron) not generally helpful for managing
opioid-mediated NV• Haloperidol most potent antidopaminergic, followed by prochlorperazine• promethazine has minimal antidopaminergic properties• metoclopramide (Reglan) binds few receptors relevant to NV• useful only for problems with motility and distention
Bowel obstruction• most often associated with pelvic cancer, especially ovarian and colon• symptoms include NV and cramping abdominal pain• treatments surgical, interventional, and medical• usually possible to avoid IV and nasogastric tube• Surgical treatment: includes venting gastrostomy tubes for small bowel obstructions but
not for colonic obstructions• Drug therapy: cocktail of opioids, anticholinergic agent, and somatostatin (octreotide)• opioids—help relieve pain; evidence suggests they do not increase risk for paralytic ileus• dopamine antagonist—eg, haloperidol; much lower dose (ie, 0.5 to 2 mg every 4-6 hr) of
haloperidol required than for psychosis (5 to 10 mg)• spasms; agents include glycopyrrolate or scopolamine• glycopyrrolate administered IV or PO) and does not cross blood-brain barrier or cause
changes in mental status• scopolamine administered by patch and crosses blood-brain barrier• consider prokinetic drugs for partial small bowel obstruction and discontinue if pain
increases• octreotide—inhibits splanchnic blood flow and decreases secretions from intestinal
mucosa to diminish distention• administered IV or subcutaneously• Effective dose usually <400 g/day
Cough• highly debilitating; 40% of patients suffer from cough at end of life• drugs associated with cough include• angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory agents (NSAIDs),
and propellants in inhaled medications• Treatment: American College of Chest Physicians (ACCP) recommends against use of prescription
and over-thecounter cough syrups• sweet syrups (eg, honey) possibly effective for relief of cough• Opioids first-line therapy for cough in patients with cancer• all opioids have similar effect• for patients already taking an opioid, study suggested low dose of oxycodone effective a 5 mg po
bid• Expectorants consider for wet cough• guaifenesin or inhaled acetylcysteine• avoid in patients with reactive airway disease because of bronchospasm• consider nebulized 3% to 10% hypertonic saline instead• use caution in patients with impaired cough reflex because of risk for aspiration• benzonate—local anesthetic second-line in addition to opioids• anticholinergics—play role if upper airway secretions contribute to cough (eg, scopolamine and
glycopyrrolate);• inhaled lidocaine—(used off-label) • bupivacaine block upper airway stretch receptors• Patients must not eat or drink for 1 hr after inhalation as precaution against aspiration
Constipation• experienced by 90% of patients in advanced phases of illness• mostly due to opioids• prevention critical, and all patients on opioids need bowel regimen• Constipation can cause fecal impaction and diarrhea• Digital rectal examination and history important• preventive regimen includes stool softener, eg, docusate (Colace), and stimulant laxative, eg, senna or
bisacodyl (Dulcolax)• add osmotic laxative if necessary• Induced by opioids• tolerance rarely develops• not centrally mediated, limited to gut• previously used oral naloxone (opioid antagonist with poor bioavailability)• However high doses needed cause opioid withdrawal and reversal of analgesia• methylnaltrexone—mu receptor antagonist that works only in gut• given as subcutaneous injection• lower dose works better• in studies, 60% of patients have bowel movement (BM) within 4 hr and 70% within• first 24 hr• in clinical use, 54% have BM• no tolerance observed• average dose 8 mg (based on weight)• Comes in prefilled syringe• side effects include abdominal cramping, gas, and diarrhea
Metastatic bone pain• almost 500,000 new patients per year• often associated with cancers of lung, breast, and prostate and multiple myeloma• goals of treatment include• control of pain and prevention of fractures• Medical therapy: consider calcitonin because of low risk, although often not efficacious, and effect short-lived when
present• opioids—effective only 50% of time• NSAIDs—treat inflammation in bone• avoid indomethacin in elderly patients because of associated CNS toxicity and mental status changes• ibuprofen (eg, Motrin) at anti-inflammatory doses (ie, 600 to 800 mg/day)• corticosteroids—mechanism similar to that of NSAIDs• dose not standardized• prednisone and dexamethasone (eg, Decadron) most commonly prescribed• Dexamethasone used at 16 to 32 mg/day for bone pain• start at 2 to 4 mg twice daily because of dose-limiting toxicity• Discontinue if not effective after 7 days at 16 to 24 mg• prednisone used at 30 to 40 mg/day • dexamethasone has lower mineralocorticoid activity than prednisone• bisphosphonates—(eg, zoledronic acid and pamidronate) decrease bone pain• most effective in breast and prostate cancer• inhibit bone resorption by osteoclasts• reduce number of fractures and skeletal events by 30%• reduce pain by 30% to 40% in 30% to 50% of patients• effects last 3 to 4 wk• if first infusion not effective, try second infusion, but if still ineffective, discontinue for pain (may continue for
fractures)
Metastatic bone pain• Radiation therapy: effects on pain seen in 2 days to 2 weeks• limited by number of areas affected by metastasis• Radiopharmaceuticals: Strontium, best evidence for efficacy in
breast and prostate cancer; helpful with multiple foci of metastasis
• improve pain in 30% of patients• patient must have >12 wk of life remaining• analgesia occurs as soon as 3 days, usually 2 wk• worsened pain (flare) within first week because of inflammatory
effect (actually good prognostic sign)• myelosuppression can occur (cancer patients who already have
myelosuppression from tumor not candidates)• Neuropathic bone pain: component of bone pain• early data show benefit of gabapentin (Neurontin) or pregabalin
Psychiatric symptoms
• depression not part of dying but manageable symptom• antidepressants can help achieve better pain control• anxious depression often misdiagnosed as anxiety disorder• methylphenidate—fastest acting antidepressant• appropriate for patients with life expectancy of weeks• response observed within 1 or 2 doses• well tolerated in geriatric population• begin dose at 2 to 5 mg once daily and add 2.5 mg if no effect• ultimately may need only 5 mg twice daily• duloxetine (Cymbalta) and venlafaxine (Effexor) appropriate for patients
with depression and neuropathic pain• fluoxetine and venlafaxine appropriate to activate patients with
psychomotor retardation• Mirtazapine (Remeron) useful for depression with insomnia• Also stimulates appetite in patients without severe depression when given
at 7.5 mg at night• citalopram, escitalopram, and paroxetine helpful for depression with anxiety
Suggested Reading• Abernethy AP et al: Detailing of gastrointestinal symptoms in cancer• patients with advanced disease: new methodologies, new insights,• and a proposed approach. Curr Opin Support Palliat Care 3:41,• 2009; Al-Khafaji A, Min Cho S: Making palliative care more “palatable.”• Crit Care Med 37:2492, 2009; Biermann JS et al: Metastatic• bone disease: diagnosis, evaluation, and treatment. J Bone Joint• Surg Am 91:1503, 2009; Dalal S et al: Is there a role for hydration at• the end of life? Curr Opin Support Palliat Care 3:72, 2009; Desandre• PL, Quest TE: Management of cancer-related pain. Emerg Med• Clin North Am 27:179, 2009; Di Giulio P et al: Dying with advanced• dementia in long-term care geriatric institutions: a retrospective• study. J Palliat Med 11:1023, 2008; Guay DR: Methylnaltrexone• methobromide: the first peripherally active, centrally inactive opioid• receptor-antagonist. Consult Pharm 24:210, 2009; Innes S, Payne S:• Advanced cancer patients’ prognostic information preferences: a review.• Palliat Med 23:29, 2009; Jacobsen J, Jackson VA: A communication• approach for oncologists: understanding patient coping and• communicating about bad news, palliative care, and hospice. J Natl• Compr Canc Netw 7:475, 2009; Kierner KA et al: Attitudes of patients• with malignancies towards completion of advance directives.• Support Care Cancer May 31, 2009 [Epub ahead of print]; Messinger-• Rappaport BJ et al: Advance care planning: Beyond the living• will. Cleve Clin J Med 76:276, 2009; Monturo C: The artificial• nutrition debate: still an issue … after all these years. Nutr Clin Pract• 24:206, 2009; Phelps AC et al: Religious coping and use of intensive• life-prolonging care near death in patients with advanced cancer.• JAMA 18:301, 2009; Price A, Hotopf M: The treatment of depression• in patients with advanced cancer undergoing palliative care.• Curr Opin Support Palliat Care 3:61, 2009; Rondeau DF, Schmidt• TA: Treating cancer patients who are near the end of life in the emergency• department. Emerg Med Clin North Am 29:341, 2009; Sanft• TB, Von Roenn JH: Palliative care across the continuum of cancer• care. J Natl Compr Canc Netw 7:481, 2009; Wee B: Chronic cough.• Curr Opin Support Palliat Care 2:105, 2008; Wright AA et al: Associations• between end-of-life discussions, patient mental health,• medical care near death, and caregiver bereavement adjustment.• JAMA 300:1665, 2008; Zaider T, Kissane D: The assessment and• management of family distress during palliative care. Curr Opin Support• Palliat Care 3:67, 2009.
dyspnoea
• Breathlessness or dyspnoea is the unpleasant awareness of difficulty in breathing
• dyspnoea, like pain, is subjective and involves both the perception of breathlessness and the reaction of the patient to it
• dyspnoea is always associated with some degree of anxiety, which in turn will make the breathlessness worse
Treatment• treatment directed at the specific cause, where
possible and appropriate• general measures• calm, reassuring attitude• nurse patient in position of least discomfort• physiotherapy• improve air circulation• distraction therapy• relaxation exercises• breathing control techniques• counselling
Is O2 saturation is a good measure of dyspnea?
• True
• False
Answer
• False
• Dyspmea is a subjective symptom
Treatment• oxygen• if hypoxic• if it improves symptoms (terminal care situation)• Patients often feel better but it may be just do to movement of air on the face• A fan or open window may help just as much in certain situations• bronchodilators if there is a reversible element to the bronchial obstruction• corticosteroids• effective bronchodilators• for dyspnoea due to multiple metastases, lymphangitis carcinomatosis and pneumonitis• opioids—the most useful agents in the treatment of dyspnoea• nebulised morphine• effective for some patients, although controlled studies do not support its use• risk of bronchospasm• aid expectoration• steam, nebulised saline• mucolytic agents• expectorants• Physiotherapy• reduce excess secretions• anticholinergics• antitussives if dyspnoea exacerbated by coughing• anxiolytics
Examples of drug therapy• bronchodilators• salbutamol by metered aerosol or 2.5-5 mg by nebuliser, q4-6h• ipratropium by metered aerosol or 250-500 µg by nebuliser, q6h• aminophylline, theophylline PO• corticosteroids• prednisolone 40-60 mg/d PO or dexamethasone 8-12 mg/d PO• wean to the minimum effective dose after a few days• opioids• morphine 5-10 mg PO, q4h or 4-hourly PRN and titrate• 50% increase in dose for patients on morphine for pain• nebulised morphine not recommended• anxiolytics• diazepam 2 mg PO q8h ± 5-10 mg nocte• alprazolam 0.25-0.5 mg SL, q1-2h• lorazepam 0.5-1 mg SL, q4-6h• mucolytics (for sputum retention)• humidified air (steam, nebulised saline)• acetylcysteine 10%, 6-10 ml by nebuliser, q6-8h• anticholinergics (for excessive secretions)• glycopyrrolate 0.2-0.4mg SC q2-4h or 0.6-1.2mg/24h CSCI• hyoscine hydrobromide 0.2-0.4mg SC q2-4h or 0.6-1.2mg/24h CSCI• Terminal Care• treatment should be purely symptomatic in the last week or days of life• investigations should be avoided• antibiotic therapy is usually not warranted• if of benefit, bronchodilator therapy can be continued by mask.• unconscious patients who still appear dyspnoeic should be treated with morphine SC•
TERMINAL RESPIRATORY CONGESTION
('DEATH RATTLE')• Terminal respiratory congestion is the rattling, noisy or gurgling respiration of some patients
who are dying• Cause• accumulation of pharyngeal and pulmonary secretions in patients who are unconscious or semi-conscious
and too weak to expectorate• Treatment• therapy is often more for the comfort of the relatives and other patients, as most of the
patients are no longer aware of their surroundings• position the patient on their side• oropharyngeal suction should be reserved for unconscious patients• anticholinergic drugs to suppress the production of secretions• hyoscine hydrobromide• 0.4mg SC, ± repeat at 30min, then q2-4h or 0.6-1.2mg/24h CSCI• antiemetic; sedative; occasional agitated delirium• glycopyrollate• 0.2-0.4mg SC, ± repeat at 30min, then q4-6h or 0.6-1.2mg/24h CSCI• less central and cardiac effects• atropine• 0.4-0.8mg SC q2-4h• may cause tachycardia after repeated injections• transdermal scopolamine patches• hyoscine hydrobromide 1.5mg patch q72h• onset of action is delayed for several hours during which other anticholinergic treatment needs to be given• reassure relatives that the noisy breathing is not causing any added suffering for the patient
Pharmacologic Pearls for End-of-Life Care
• As death approaches, a gradual shift in emphasis from curative and life prolonging therapies toward palliative therapies can relieve significant medical burdens and maintain
a patient's dignity and comfort. • Pain and dyspnea are treated based on severity, with stepped interventions, primarily
opioids. • Common adverse effects of opioids, such as constipation, must be treated proactively;
other adverse effects, such as nausea and mental status changes, usually dissipate with time.
• Parenteral methylnaltrexone can be considered for intractable cases of opioid bowel dysfunction.
• Tumor-related bowel obstruction can be managed with corticosteroids and octreotide. • Therapy for nausea and vomiting should be targeted to the underlying cause; low-dose
haloperidol is often effective. • Delirium should be prevented with normalization of environment or managed medically.
Excessive respiratory secretions can be treated with reassurance and, if necessary, drying of secretions to prevent the phenomenon called the "death rattle."
• There is always something more that can be done for comfort, no matter how dire a situation appears to be.
• Good management of physical symptoms allows patients and loved ones the space to work out unfinished emotional, psychological, and spiritual issues, and, thereby, the
opportunity to find affirmation at life's end.
Clinical recommendation• Opioids should be used for dyspnea at the end of life.
• A• Multiple studies have shown that nebulized opioids have no benefit over systemic administration in
terms of effect or adverse effects.• Opioids should be used for pain at the end of life.
• C• The ethical limitations of withholding opioids have limited the study of opioids versus placebo, except
in neuropathic pain.• Stimulant laxatives are effective for prevention and treatment of constipation in persons on opioids.
• C• There is no clear benefit of one regimen over another.
• Methylnaltrexone (Relistor) can be used for treatment of opioid bowel dysfunction.• B
• Methylnaltrexone has recently been added as a treatment option.• Corticosteroids can be used for malignant bowel obstruction.
• B• Haloperidol (formerly Haldol) is effective for nausea and vomiting.
• B• 34, 35
• Hyoscyamine (Levsin) should be used for the "death rattle" (excessive respiratory secretions).• C
Methylnaltrexone (Relistor)• HIGHLIGHTS OF PRESCRIBING INFORMATION• These highlights do not include all the information needed to use• RELISTOR safely and effectively. See full prescribing information for• RELISTOR.• RELISTOR(methylnaltrexone bromide) Subcutaneous Injection• Initial U.S. Approval: 2008• ————————— INDICATIONS AND USAGE —————————• RELISTOR is indicated for the treatment of opioid-induced constipation in• patients with advanced illness who are receiving palliative care, when• response to laxative therapy has not been sufficient. Use of RELISTOR• beyond four months has not been studied. (1)• ——————— DOSAGE AND ADMINISTRATION ———————• RELISTOR is administered as a subcutaneous injection. The usual schedule is• one dose every other day, as needed, but no more frequently than one dose in• a 24-hour period. (2.2)• The recommended dose of RELISTOR is 8 mg for patients weighing 38 to• less than 62 kg (84 to less than 136 lb) or 12 mg for patients weighing 62 to• 114 kg (136 to 251 lb). Patients whose weights fall outside of these ranges• should be dosed at 0.15 mg/kg. See the table below to determine the correct• injection volume. (2.2)• Patient Weight• Pounds Kilograms• Injection• Volume Dose• Less than 84 Less than 38 See below* 0.15 mg/kg• 84 to less than• 136• 38 to less than 62 0.4 mL 8 mg• 136 to 251 62 to 114 0.6 mL 12 mg• More than 251 More than 114 See below* 0.15 mg/kg• *The injection volume for these patients should be calculated using one of• the following (2.2): Multiply the patient weight in pounds by 0.0034 and round up the• volume to the nearest 0.1 mL. Multiply the patient weight in kilograms by 0.0075 and round up• the volume to the nearest 0.1 mL.• In patients with severe renal impairment (creatinine clearance less than• 30 mL/min), dose reduction of RELISTOR by one-half is recommended. (8.6)• ——————— DOSAGE FORMS AND STRENGTHS ———————• 12 mg/0.6 mL solution for subcutaneous injection in a single-use vial. (3)• —————————— CONTRAINDICATIONS ————————— RELISTOR is contraindicated in patients with known or suspected• mechanical gastrointestinal obstruction. (4)• ——————— WARNINGS AND PRECAUTIONS ————————• If severe or persistent diarrhea occurs during treatment, advise patients to• discontinue therapy with RELISTOR and consult their physician. (5.1)• —————————— ADVERSE REACTIONS ——————————• The most common (> 5%) adverse reactions reported with RELISTOR are• abdominal pain, flatulence, nausea, dizziness, diarrhea and hyperhidrosis.
PAIN AND DYSPNEA• Pain and dyspnea are treated based on severity, with stepped
interventions, primarily opioids. • Dyspnea that persists despite optimal respiratory treatment is sensed in
the same central nervous system structures as pain and should be considered as if it were "lung pain."
• Moderate to severe dyspnea and pain may be treated with oral or parenteral opioids.1,6,7
• Proven nonpharmacologic strategies should be optimized.8 • Using one of many validated scales, physicians can support patients'
efforts to set realistic goals for function and pain or dyspnea levels. • Recommended scales should include assessment of intensity and quality
of pain, as well as function.• Scales that include a nonverbal 0 to 10 line, faces scales, and intensity
descriptive scales have proven reliable in persons with Mini-Mental State Examination scores averaging as low as 15.3 out of 30.9
• For nonverbal patients, other scales, such as the Pain Assessment in Advanced Dementia scale, are necessary
Pain Control• Nonopioid pain therapies should be optimized; nonsteroidal anti-inflammatory drugs, steroids,
and bisphosphonates are particularly effective for bone pain.1,4,6 • A variety of medications are also available for neuropathic pain, a subject beyond the scope of
this article.• The fear that opioids will hasten death is an inappropriate barrier to their use, assuming proper
dose initiation and escalation are used.11 • Opioids are a central part of pain treatment in palliative care, including treatment of
nonmalignant and neuropathic pain.12 • Titration for effective pain management should be rapid and consistent, using parenteral or
oral short-acting medications, with dosing intervals set according to peak effects rather than duration of action.13
• Breakthrough dosing must be proportionate to the total 24-hour dose of opioids. • It should be 10 to 20 percent of the 24-hour oral morphine equivalent (or 50 to 150 percent of
the hourly intravenous rate). • A common error is the administration of 5 to 10 mg of oxycodone (Roxicodone) for
breakthrough pain when a patient is tolerating high long-acting doses. • For example, if a patient requires 1,000 mg of oral morphine equivalent every 24 hours, the
appropriate breakthrough dose would be 60 to 120 mg of oxycodone. • Breakthrough doses should treat unpredictable spikes in pain and prevent breakthrough pain
when predictable, such as before necessary turning or transfers. Increases in the basal dose should be 25 to 50 percent for mild to moderate pain and 50 to 100 percent for severe pain.
Pain Control• To control symptoms, breakthrough doses should be administered each time an increase in a basal dose is initiated. • Preparations that combine an opioid with acetaminophen, aspirin, or ibuprofen should be avoided because of the risk of
toxicity above established dose ceilings of the nonopioid.14• Many patients with terminal illnesses and their families are reluctant to begin opioid therapy because of the stigma
associated with addiction. • Preparatory reassurance, education of the patient and family, and use of the term "opioids" instead of "narcotics" helps.
• If a persistent objection is raised to initiating one opioid, another can be substituted. • Failure of one opioid at the highest tolerated dose may be treated by rotation to another opioid.
• Reduce dose equivalents by 50 to 75 percent when rotating opioids in the context of well-controlled pain to compensate for incomplete cross-tolerance.
• Dose ceilings of opioids are variable and often high. • Methadone is among the most difficult and dangerous to use, but has advantages in cost and effectiveness. Physicians
should consider consultation with a palliative care specialist before using methadone, unless they are familiar with its interactions, variable duration of effect, adverse effects, unique comparative potency with morphine, and risk of toxicity,
including QT interval prolongation. • The New Hampshire Hospice and Palliative Care Organization's opioid use guidelines (http://www.nhhpco.org/opioid.htm)
provide a quick reference card that reviews opioid management and includes equianalgesic tables, opioid rotation guidelines, and a methadone and morphine nomogram.13
• Common causes of a partial response or lack of response to opioids include: neuropathic pain; social, psychological, or spiritual pain; substance use disorders; and misinterpretation of symptoms for pain, particularly in persons who are
cognitively impaired.• Sometimes, aggressive therapies for pain control, such as surgery, radiation, regional nerve blocks, and intraspinal or
epidural delivery devices, are appropriate and necessary when basic measures fail and interventions are consistent with patient goals.
• Throughout treatment, physicians must evaluate the "total pain syndrome" and align treatment with the causes of pain as much as possible, optimizing psychological, social, and spiritual treatments and avoiding inappropriate pharmacologic
management of psychosocial or spiritual pain.
Opioids• Steps to Rotate or Change Opioids
1. Calculate 24 hr dose of current drug.2. Translate that to equianalgesic 24 hr dose of oral morphine. 3. Calculate 24 hr equianalgesic dose of new drug and reduce dose to 50-75% of calculated dose if pain is well controlled; use 100% otherwise.4. Divide to attain appropriate interval and dose for new drug. 5. Always have breakthrough dosing available while making changes.
• Breakthrough Dosing (immediate release (IR) / short acting meds only)50-150% of IV basal dose q15 minutes OR 10-20% of 24 hr oral dose q1hr.
• Changing Basal Rates (due to inadequate baseline pain control)Increase rate by 50-100% of IV basal rate q15 minutes.Give a breakthrough dose each time basal rate is increased.
• Ceiling Effect = uncontrollable pain with appropriate increases in dose OR side effects such as neuroexcitation, myoclonus, or protracted central effects. a) Rotate to another opioid as above.b) Dose reduce opioid by 25-50% with addition of other treatment for pain.c) Treat side effect +/- dose reduce.
• Partial Reversal with Naloxone: ONLY for overdose in rare cases: à mix 0.4 mg amp with saline to make 10cc + administer 0.5 -1 ml (0.02-0.04 mg) IV/SC q2-5 minutes until response; naloxone effect shorter in duration than long acting opioids and close monitoring +/- repeat doses sometimes necessary.
METHADONE
• METHADONECAUTION: Use only with experience or training in pain mgt.- Dosing interval is titrated for analgesic effect q4-12h; start with q8h. - Delayed side effects @ Day 4 after initiation: highly lipid soluble with potential delayed and prolonged side effects that outlast analgesic efficacy.- Prolonged QT at high dose>200 mg/day; interactions at CYP450 (esp 2D6, 3A4)- Common drugs that increase methadone effect: SSRI’s (fluoxetine), TCA’s (amitriptyline), macrolides, metronidazole, grapefruit juice.- Decrease methadone effect: antiretrovirals, carbamazepine, rifampin, phenytoin.
• Rotation to Methadone Day 1: Calculate dose (above). Give 33% methadone dose + 66% of present drug.Day 2: Give 66% methadone dose + 33% present drug.Day 3: Give 100% methadone dose.
• Rotation from MethadoneCaution: Ratios above do not necessarily apply – consult an expert.
Transdermal Fentanyl
• Rotating to and from Transdermal Fentanyl (TDF)Shortcut: Transdermal Fentanyl (mcg/hr) X 2 = approx 24 hr dose of MS PO(mg).From TDF: Start new drug at 50% dose for 6-24 hrs after removal of TDF. To TDF: Continue old drug at 50% dose for 6-24 hrs after starting TDF.
Bowel Routine• Bowel Routine
All patients on opioids should be on a baseline bowel routine such as one or more of the following: Senna + docusate (Senokot S) 1-2 tabs twice daily. MOM 30-60 cc twice to three times daily. Lactulose 30-60 cc twice to three times daily. PEG solution: Miralax 1-4 T daily or 4-8 oz of GoLytely titrated to effect.
• STEP UP: If symptoms of constipation, lack of BM for specified period of time, or risk factors present such as immobilization, hospitalization, significant increase in opioids: Double dose of regimen above OR add 2nd agent such as Lactulose or Miralax.
RECTAL IMPACTION or significant rectal stool: Empty rectum first with: Bisacodyl 10 mg pr bid for 1-3 days or Fleet or other enemas until clear. Then proceed with stepped up bowel regimen as above.
Opioid Adverse Effects• Nausea and vomiting, sedation, and mental status changes are common with opioid initiation and most often fade within a few
days.• When initiating an opioid, prophylactic use of an antiemetic for three to five days can be effective in the susceptible patient.15 • Persistent nausea and vomiting is related to chemoreceptor trigger zone stimulation, and can be treated with a combination of
dose reduction, opioid rotation, and antiemetics.16 • Undesirable sedation can be addressed with low-dose methylphenidate (Ritalin), which can be rapidly tapered when no longer
needed.17 • Allergy to opioids usually amounts to nothing more than sedation or gastrointestinal adverse effects, and can be managed
expectantly. • Localized urticaria or erythema at the site of an injection of morphine is caused by local histamine release and is not
necessarily a sign of systemic allergy.• Constipation is one adverse effect of opioids that does not extinguish with time (Table 2).18 An important principle of pain
management is that, when writing opioid prescriptions, physicians also need to write orders for the bowel preparation. Increasing fiber or adding detergents (e.g., forms of docusate) is not sufficient.
• Like pain, constipation is more easily prevented than treated. Start a conventional combination of a stimulant laxative with a stool softener (e.g., senna with docusate) or osmotic agent (e.g., polyethylene glycol solution [Miralax]) at the same time as
the opioid.19 • There is no good evidence of superiority of any one regimen over another.20 Polyethylene glycol solutions are easy to titrate,
with no maximal dose; can be given once daily; and are particularly effective with the addition of a stimulant, such as senna. • With increases in opioid dose, or with other risks of worsening constipation (e.g., change in environment, declining
performance status), the laxative dose should be doubled or therapy stepped up by adding a stronger agent. • Dosing can be ordered with the notation "hold for diarrhea" or a stepped action plan can be developed based on consistency
and frequency of stool. • Overflow diarrhea can occur with fecal impaction. Patients nearing death decrease their intake of solids, which is often
expected to cause the cessation of bowel movements. • However, 70 percent of the dry weight of stool consists of bacteria, so bowel activity can and should be maintained for
comfort.21
Treatment of Constipation
• Treatment• Dosage• Lactulose
• 15 to 30 mL orally two or three times per day• Magnesium hydroxide
• 30 to 60 mL orally at bedtime• Polyethylene glycol (Miralax)
• One or more tablespoons dissolved in 4 to 8 oz of fluid orally per day
• Senna with docusate• One to two tablets orally two to four times per day
Opioid Side Effects• Opioid bowel dysfunction that is unresponsive to aggressive conventional medications, removal of
anticholinergic or other contributing medications, enemas, opioid dose rotation, and opioid reduction may be carefully treated with methylnaltrexone (Relistor).22
• It reverses mu-opioid receptor-mediated bowel paralysis without crossing the blood-brain barrier. • In a recent industry-sponsored phase 3 trial, subcutaneous methylnaltrexone at 0.15 mg per kg led to a
bowel movement within four hours in 48 percent of terminally ill patients with opioid bowel dysfunction versus 15 percent with placebo, with a median time of 45 minutes to first bowel movement versus 6.3
hours with placebo.23 • A more recent study found a dose of 5 mg to be effective, but did not find a dose response above 5
mg.24 • Methylnaltrexone is approved by the U.S. Food and Drug Administration for this indication.
• Toxic effects of opioids at higher dose ranges or with rapidly escalating doses include forms of neuroexcitation, such as hyperalgesia, delirium, and myoclonus.25
• A common pitfall is to confuse these symptoms with worsening pain and further escalate the dose, which may worsen neuroexcitation and increase hyperalgesia, thereby exacerbating total pain.
• Opioid reduction or rotation, with the addition of adjuncts for pain control, is indicated instead. • Ketamine (Ketalar) can be an effective adjunct in severe cases, but requires experience or
consultation.26• Unintentional overdose of an opioid can usually be managed expectantly; however, if partial reversal is
necessary, very low-dose naloxone (formerly Narcan) can be quickly administered by giving 0.01- to 0.04-mg (or 1.5 mcg per kg) intravenous or intramuscular boluses every three to five minutes, titrated to respiratory rate or mental status (mix one 0.4 mg per mL ampule of naloxone with saline to make 10 mL,
which equals 0.04 mg per mL).27 • Continued close monitoring is necessary because duration of opioid effect may outlast naloxone.
Bowel Obstruction Nausea• Mechanical bowel obstruction is commonly associated with ovarian28 and colon cancers.29
• If this cause is known or suspected, it is acceptable to opt not to proceed to invasive intervention urgently.30 • Surgery or venting gastrostomy tube insertion should be undertaken only after careful consideration, because of
potential procedural complications, lack of evidence for life prolongation, and recurrence rates up to 50 percent.31
• Endoscopic bowel stenting can be a reasonable option for esophageal or duodenal obstruction. • Standard conservative therapies may include cessation of oral intake, transient nasogastric suction, antiemetics,
octreotide (Sandostatin), and corticosteroids. • Octreotide inhibits the accumulation of intraluminal intestinal fluid and can be administered subcutaneously or
intravenously at 50 to 100 mcg every six to eight hours and titrated rapidly to effect.32 • It is also available in an intramuscular depot form, but this form costs more.
• Dexamethasone six to 16 mg intravenously daily may resolve a bowel obstruction caused by edema from gastrointestinal or ovarian cancer.33
• Although there is no change in mortality at one month, a review of 10 trials confirmed that corticosteroids shrink swelling around the tumor and can allow resumption of oral intake with reinstatement of normal bowel activity
(number needed to treat = 6).33 • Tapering off corticosteroids should not be undertaken in this circumstance unless indicated for other reasons.• Persistent nausea and vomiting (without bowel obstruction) should be carefully investigated and treatment
directed to the underlying cause, most commonly in the central nervous system or the gastrointestinal tract (Tables 3 and 4).34
• If one medication fails, substitute another drug from a different class. Promethazine (Phenergan), a sedating antihistamine, is relatively ineffective in palliative care and is overused.
• As noted in a comprehensive review,34 off-label use of haloperidol (formerly Haldol), a low-cost antiemetic, can be at least as effective as ondansetron (Zofran).35
• It is best used at lower doses than for psychosis and can be combined with other interventions.
Choice of Antiemetic Based on Cause of Nausea and
Vomiting• Cause of nausea and vomiting• Antiemetic
• Anxiety, anticipatory, psychologic• Benzodiazepines, canniboids
• Bowel obstruction• Octreotide (Sandostatin; see text)
• Gastroparesis• Metoclopramide (Reglan)
• Increased intracranial pressure, central nervous system pain• Dexamethasone
• Inner ear dysfunction (rare in palliative care)• Anticholinergics, antihistamines
• Medication (primarily chemotherapy)• 5-HT3 and dopamine receptor blockers• Metabolic (e.g., uremia, cirrhosis)
• 5-HT3 and dopamine receptor blockers, antihistamines, steroids• Opioid bowel dysfunction• Methylnaltrexone (Relistor)
DELIRIUM AND THE "DEATH RATTLE"
• Up to 85 percent of patients experience delirium in the last weeks of life, up 46 percent with agitation.36 • It manifests as a sudden onset of worsened mental status with agitation.
• This distressing symptom often occurs in those with rapidly escalating opioid requirements and can be challenging for all.
• Prevention can be undertaken in all patients at risk by providing continuity of care; keeping familiar persons at the bedside; limiting medication, room, and staff changes; limiting unnecessary catheterization; and avoiding
restraints. • Causes such as polypharmacy, opioid toxicity, urinary retention, constipation, and infection should be ruled
out. • For mild to moderate cases, add haloperidol.37
• More severe terminal delirium can be managed with midazolam infusion or other forms of sedation. • These interventions, which in conjunction with high-dose opioids can induce "double effect" (the outcome of
hastening death when the intention is purely to relieve symptoms), require expertise and can lead to ethical controversy.38,39
• Consultation with a palliative care specialist is recommended when delirium, pain, or any other symptoms appear to be intractable.
• As mental status changes occur during the dying process, patients lose the capacity to clear upper respiratory secretions ("death rattle").
• Nonpharmacologic interventions, such as positioning to facilitate drainage and very gentle anterior suctioning (not deep), are an appropriate initial response.
• Pharmacologic interventions may include hyoscyamine (Levsin), glycopyrrolate (Robinul), scopolamine, octreotide, and the oral use of atropine eyedrops (Table 5).40
• Patients do not report experiencing these sounds to be as distressing as family members or caregivers find them, and education regarding this issue may be as effective as positioning and medication.41
• A randomized trial is presently underway comparing the effectiveness of different strategies.
Treatment of Excessive Respiratory Secretions
• Treatment• Dosage
• Atropine eye drops 1%• One to two drops orally or under the tongue; titrate every eight
hours• Glycopyrrolate (Robunil)
• 1 mg orally or 0.2 mg subcutaneously or intravenously every four to eight hours as needed
• Hyoscyamine (Levsin)• 0.125 to 0.5 mg orally, under the tongue, subcutaneously, or
intravenously every four hours as needed• Scopolamine
• One to two patches applied topically and changed every 48 to 72 hours
