at: inbox
Palliative Care - Care of the Imminently Dying Patient - Fast Facts | NEJM Resident 360
Providing high-level, evidence-based, empathetic care at the end of life is an important skill for all clinicians. Comfort-focused care requires a nuanced approach to symptom management, offering medical, psychosocial, and spiritual support to both the patient and family. Specific skills regarding communication, symptom management, and prognostication are discussed in this section.
Communication
Goals-of-care conversations for patients approaching the end of life should remain patient-centered, with emphasis on their goals and values. The table below provides a summary of recommended communication techniques to help terminally ill patients identify their preferences. Further details regarding core communication skills are covered in the section Discussing Goals of Care and Prognosis.
(Source: Comfort Care for Patients Dying in the Hospital. N Engl J Med 2015.)
Once the decision has been made to proceed with comfort-focused care in the hospitalized patient near the end of life, ongoing daily assessments are necessary for worsening or new symptoms that need to be managed aggressively. The following table provides general guidelines for clinicians providing comfort care for patients who are near the end of life.
(Source: Comfort Care for Patients Dying in the Hospital. N Engl J Med 2015.)
Symptom Management
Pain
Pain is not only common but often the most feared symptom experienced by patients at the end of life. Ongoing assessment is essential to ensuring comfort. For somnolent patients, attention should be paid to nonverbal indicators of pain (e.g., furrowing of the brow, grimacing, rubbing a part of the body repetitively, or moaning). The table below summarizes recommendations for pain management of acute pain for actively dying patients. An additional route of administration that is more common for patients at the end of life is the subcutaneous route.
For more-detailed information on pain management, see the section on this topic in this rotation guide.
(Source: Comfort Care for Patients Dying in the Hospital. N Engl J Med 2015.)
Dyspnea
The fear of “suffocating” or “drowning” is prominent for patients and family members when discussing the end of life. This can cause significant anxiety for the patient and worsen their shortness of breath. Reassurance and aggressive symptom management are imperative to minimize suffering for patients with shortness of breath. The first-line therapy for dyspnea is typically medical management of the underlying cause. However, if medical management is not adequate, opioids are appropriate. The use of opioids for management of dyspnea is similar to their use in pain management, with frequent as-needed dosing. In general, smaller doses of opioids can be used to achieve symptomatic relief for dyspnea. Supplemental oxygen has not been proven to provide any benefit in patients who are terminally ill with cancer or nonhypoxic heart failure but may provide symptomatic relief in patients with nonhypoxic chronic obstructive pulmonary disease (COPD). For more on management of dyspnea, see the section on Dyspnea in this rotation guide.
Xerostomia
Dry mouth is a common symptom at the end of life, caused by medications (e.g., opioids, anticholinergics) and dehydration. Good oral care, with mouth swabs for comfort and emollient to the lips, as well as discontinuation of contributing medications can aid in relieving the discomfort caused by dry mouth. Additionally, if loved ones can assist with swabbing the mouth, it gives them the opportunity for hands-on care.
Excessive Oral and Pharyngeal Secretions
Excessive secretions are common at the end of life; patients lose the ability to safely manage saliva as they become weaker and lose an effective cough reflex. The average life expectancy after development of gurgling sounds of the throat (commonly referred to as the “death rattle”) is 24 hours. Repositioning and turning the patient is considered first-line therapy. This symptom is quite distressing to loved ones but is not for patients, so reassurance to the family can be helpful. Deep suctioning should be avoided because it can be uncomfortable for patients without providing a therapeutic benefit. A short-term trial of glycopyrrolate is reasonable to consider, but in general, education and reassurance are the recommended first steps.
Nausea and Vomiting
Common conditions that occur at the end of life and can cause nausea/vomiting include malignant bowel obstruction, uremia, medications, gastroparesis, ascites, and increased intracranial pressure. In general, as discussed in the section on Nausea and Vomiting in this rotation guide, treatment should be directed at the affected neural pathway or underlying cause. However, nausea and vomiting at the end of life are generally secondary to multiple causes; therefore, haloperidol and metoclopramide are the recommended first-line therapies.
Anorexia and Cachexia
No specific medical treatments are recommended for the treatment of poor appetite at the end of life. Evidence does not support the use of artificial hydration or nutrition. Use of artificial means to support fluid or nutritional status may result in fluid overload in end-of-life patients and does not alleviate the symptoms associated with dehydration.
Fever
Fevers are a common occurrence at the end of life, with infection, medications, neurologic injury, and underlying neoplasm potentially playing roles. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are considered first-line therapies.
Delirium
Terminal delirium is a common syndrome at the end of life and is caused by multiple factors, including multi-organ failure, medications, pain, infections, and illness severity. Encephalopathy can be especially distressing for families, as agitation is commonly associated with a fear of dying. Little-to-no evidence exists to guide decision-making on the choice of pharmacologic therapy. Haloperidol is considered the preferred initial treatment for agitation or hyperactive delirium.
Treatment Recommendations for Symptoms at the End of Life
(Source: Comfort Care for Patients Dying in the Hospital. N Engl J Med 2015.)