End of Life
Symptom Management
Dec 3, 2014
Mudit Dabral
Rosene Pirrello
Objectives
 Understand concept of death
 Identify & manage common symptoms
Last Hours of Living
 Everyone will die
 <10% suddenly
 >90% prolonged illness
 Time course unpredictable
 Need to review the plan regularly
Palliative Care
 Affirms life
 Regards dying as a normal process
 Neither hastens nor postpones death
 Relieves symptoms
Palliative Care
 Integrates medical, psychological & spiritual
aspects of care
 Is often a support system to patients &
family
Gradual Symptoms
 Anorexia (loss of appetite)
 Cachexia (Weight loss)
Anorexia & Cachexia
 Medications
 Depression
 Nausea
 Dysphagia
 Odynophagia
 Any advance disease
Anorexia & Cachexia
Reversible causes –
Medications side effects
Pain
Nausea
Constipation
Depression
Anorexia - Cachexia
 Lift dietary restrictions
 Environmental pleasantries
 Socialization
 Small portions
 Oral hygiene
Anorexia - Cachexia
 Metoclopramide
 Magesterol acetate
Fatigue
 ? Given up
 ? Not fighting
Fatigue
Little is known about
Pathophysiology & treatment
Fatigue
Reversible Causes:
Medications
Dehydration
Anemia
Electrolyte imbalance
Suboptimal sleep
Fatigue
Give patient permission to rest
Clarify the role of underlying disease
Fatigue
 Steroids
 Dexamethasone (2-20mg/d)
 Psychostimulants (methylphenadate
2.5-15 mg q AM & noon)
Constipation
 Medications
 Decreased motility
 Impaction
 Mechanical obstruction
 Dehydration
 Metabolic (Hypercalcemia, Hypokalemia)
Constipation
 Treat the cause
 Laxatives - Stimulants, Osmotic
 Prokinetics
 Nausea, vomiting
 Pain
Terminal Delirium
 Hospitalized patients: 14%-56%
 Dying patients 80%-90%
End of Life
Terminal Delirium
 Can contribute to complicated &
prolonged grief disorder
 Diminishes opportunity for closure of
relationships
Delirium
 Reversible 50%
 Pain
 Constipation
 Urinary retention
 Hypercalcemia, Hepatic failure, Hypoxia
 Infection
 Dehydration
 Medications
Terminal Delirium
 Major organ failure
 Hypoxic encephalopathy
Treatment - Terminal Delirium
 Create a familiar environment
 Reassure family
 Give permission to die
 Touch
Treatment - Terminal Delirium
 Benzodiazepines - Lorazepam, Midazolam
 Neuroleptics - Haloperidol, Chlorpromazine
 Treat seizures
Respiratory Changes
 Dyspnea
 Altered breathing patterns
 Low tidal volume, Cheyne-Stroke respirations
 Accessory muscle use
 Last few reflex respiratory efforts
 “Death rattle”
Respiratory Changes
 Fears – Suffocation
 Support family
 Oxygen may prolong dying process
 Purpose of treatment is relief of unpleasant
sensation.
Dyspnea - Treatment
 Opioids (MS2.5 -20mg)
 Steroids (prednisone 10-20mg 3x a day,
Dexamethasone 8 mg per day)
 Anxiolytics (Lorazepam 0.5-2mg q 6 hrs)
 Diuretics
 Bronchodilators
 Anticholinergics (scopolamine patch,
Glycopyrrulate 1 mg-2mg q 6-8hrs )
Overall Message
Care in the last hours
is
as important as
at any other time in life
QUESTIONS?