THE FINAL DAY(S)
Keeping the Promise
of Comfort
Cancer
Stroke
Post-99
Ischemic
Encephalopathy
Discontinued
Dialysis
End-Stage
Lung Disease
• Bedridden
• Can’t clear
secretions
Pneumonia
Dyspnea, Congestion,
Agitated Delirium
NeuroDegenerative
Main Features of Approach to Care
• Perceptive and vigilant regarding changes
• “Proactive” communication with patient and family
» anticipate questions and concerns
» available
» don’t present “non-choices” as choices
• Aggressive pursuit of comfort
• Don’t be caught off-guard by predictable problems
Patient Care Challenges in the Final Days
• Functional decline- transfers, toileting
• Can’t swallow meds- route of administration
• Terminal pneumonia
» dyspnea
» congestion
» agitated delirium
• Concerns of family and friends
Concerns of Patients, Family, and Friends
• How could this be happening so fast?
• What about food & fluids?
• Things were fine until that medicine was started!
• Isn’t the medicine speeding this up?
• Too drowsy!
• Too restless!
• We’ve missed the chance to say goodbye
• What will it be like? How will we know?
Functional Decline
difficult transfers
bedridden
completely dependent
increasingly drowsy
comatose
Which Came First....
The Med Changes or the Decline?
Steady decline
Accelerated deterioration begins,
medications changed
Rapid decline due to
illness progression with
diminished reserves.
Medications questioned
or blamed
The Perception of the “Sudden Change”
When reserves are depleted, the change seems sudden
and unforeseen.
However, the changes had been happening.
Melting ice = diminishing reserves
Day 1
Day 2
Day 3
Final
Family / Friends Wanting to Intervene
With Food and / or Fluids
• distinguish between prolonging living and prolonging dying
• parenteral fluids not needed for comfort
• pushing calories in terminal phase does not improve
function or outcome
• “We can’t just let him die”
 “Not letting him die” implies that you can “make him
live”, which is not the case. The living vs. dying
outcome is dictated by the disease, not by what you or
the family decides to do.
Time that death would
have occurred without
intervention
Patient’s Lifetime
Extending the final days in terminal illness:
Prolonging life or prolonging the dying phase?
Consider the rationale of trying to prolong life by
adding time to the period of dying
OBTAINING SUBSTITUTED JUDGMENT
You are seeking their thoughts on what
the patient would want, not what they
feel is “the right thing to do”.
PHRASING REQUEST: SUBSTITUTED JUDGMENT
“If he could come to the bedside as healthy as
he was a year ago, and look at the situation for
himself now, what would he tell us to do?”
Or
“If you had in your pocket a note from him telling
you that to do under these circumstances, what
would it say?”
Usual response is for comfort
care only; emphasize then that
we have no right to do otherwise.
TALKING ABOUT DYING
“Many people think about what they might
experience as things change, and they become
closer to dying.
Have you thought about this regarding yourself?
Do you want me to talk about what changes are
likely to happen?”
First, let’s talk about what you should not
expect.
You should not expect:
– pain that can’t be controlled.
– breathing troubles that can’t be controlled.
– “going crazy” or “losing your mind”
If any of those problems come up, I will make
sure that you’re comfortable and calm, even if
it means that with the medications that we use
you’ll be sleeping most of the time, or possibly
all of the time.
Do you understand that?
Is that approach OK with you?
You’ll find that your energy will be less, as
you’ve likely noticed in the last while.
You’ll want to spend more of the day
resting, and there will be a point where you’ll
be resting (sleeping) most or all of the day.
Gradually your body systems will shut down, and at
the end your heart will stop while you are sleeping.
No dramatic crisis of pain, breathing, agitation, or
confusion will occur -
we won’t let that happen.
Basic Medications in The Final Day(s)
SYMPTOM
Pain
Dyspnea
Secretions
Restlessness
MEDICATION
Opioid
Opioid
Scopolamine
Haloperidol + Midazolam
or Lorazepam
Methotrimeprazine
National Hospice Study
Dyspnea Data
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients.
Chest 1986;89(2):234-6.
• n = 1764
• prospective
• Dyspnea incidence: 70 % during last 6 wks. of life
National Hospice Study
Dyspnea Prevalence
Prevalence of Dyspnea (%)
75
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients.
Chest 1986;89(2):234-6.
65
55
45
35
# Days Prior to Death
25
42
21
7
HOW WELL ARE WE TREATING DYSPNEA IN THE
TERMINALLY ILL?
Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P.
Dying from cancer: the views of bereaved family and friends about the experience
of terminally ill patients. Palliative Medicine 1991 5:207-214.
• n = 80 Last week of life
• severe / very severe dyspnea: 50%
 less than ½ of these were offered
effective treatment
Basic Medications in The Final Day(s)
1. Opioid - pain, dyspnea
2. Antisecretory - congestion
3. Sedative - restlessness, confusion
Examples of Opioid Prescription / Orders
In Absence of a Protocol
Example 1
Morphine 5 - 20 mg po/SL/pr q4h.
- Start with 5 mg dose. Titrate or  by 5 mg .
- Breakthrough = the current q4h dose given q1h prn.
Example 2
Hydromorphone 0.5 - 2 mg/hr IV/SQ sage.
- Start with 0.5 mg/hr. Titrate or  by 0.1- 0.2 mg/hr
- Breakthrough = the current hourly dose q30 min prn.
Sedation in Delirium if No SQ Route Available or if
Not Necessary
Mild: haloperidol 0.5 – 2 mg po or (injectable) SL bid + q6h prn
OR
risperidone 0.5 – 1 mg po bid plus q6h prn
OR
methotrimeprazine (elixir or injectable) 6.25 – 12.5 mg po/SL
q6-8h + q4h prn [NB:Taché Pharm. makes 40mg/ml elixir)
Moderate: methotrimeprazine 12.5 - 25 mg po/SL
OR
haloperidol 2.5 - 5 mg po/SL
+/-
q4h plus q1h prn
lorazepam 1 - 2 mg SL
Severe: methotrimeprazine 25 - 50 mg po/SL
OR haloperidol 5 mg po/SL
AND lorazepam 2 mg SL
q4h plus q1h prn
(Also consider chlorpromazine supps 50 - 100 mg pr q4h)
Sedation via SQ Route in Delirium
Mild: haloperidol 0.5 - 2 mg SQ bid OR
methotrimeprazine 6.25 – 12.5 mg SQ 6 - 12h
Moderate: haloperidol 2.5 - 5 mg OR methotrimeprazine 25-50mg
+
SQ q4h plus q1h prn
midazolam 2.5 - 5 mg
Severe:
haloperidol 5 mg OR methotrimeprazine 50mg
+
SQ q4h plus q1h prn
midazolam 10 – 20 mg
OR:
SQ infusion of:
methotrimeprazine 6.25 - 12.5 mg/hr + midazolam 1.25 - 5 mg/hr
CONGESTION IN THE FINAL HOURS
“Death Rattle”
• Positioning
• ANTISECRETORY: Scopolamine
 0.3 - 0.6 mg SQ q1h prn
 Transdermal Gel (Taché Pharm.) 0.25 mg/0.1ml
Give 0.5 mg q4h and q1h prn.
 Try 2-3 Transderm-V® Patches
• Consider suctioning if secretions are:
 distressing, proximal, accessible
 not responding to antisecretory agents
A COMMON CONCERN ABOUT AGGRESSIVE USE
OF OPIOIDS IN THE FINAL HOURS
How do you know that the aggressive
use of opioids doesn't actually bring
about or speed up the patient's death?
SUBCUTANEOUS MORPHINE IN
TERMINAL CANCER
Bruera et al. J Pain Symptom Manage. 1990; 5:341-344
100
90
80
Pre-Morphine
70
Post-Morphine
60
50
40
30
20
10
0
Dyspnea
Pain
Resp. Rate
(breaths/min)
O2 Sat (%)
pCO2
Typically, with excessive opioid dosing one
would see:
• pinpoint pupils
• gradual slowing of the respiratory rate
• breathing is deep (though may be shallow) and regular
COMMON BREATHING PATTERNS
IN THE FINAL HOURS
Cheyne-Stokes
Rapid, shallow
“Agonal” / Ataxic
DON’T FORGET...For death at home
• Advance Directive: no CPR
• Letters (regarding anticipated home death) to:
» Funeral Home
» Office of the Chief Medical Examiner
» Copy in the home
• physician not required to pronounce death in the
home, but be available to sign death certificate