Symptom Relief in
End of Life Care
Goals, Objectives, Standards
Apply a full set of skills in end of life care
 Bookmark websites with end of life care
information for future ongoing use
 Discuss feeling regarding death and dying
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Dying: Common Family Concerns
Is my loved one in pain; how would we
know?
 Aren’t we just starving my loved one to
death?
 What should we expect?
 How will we know that time is short?
 Should I/we stay by the bedside?
 Can my loved one hear what we are
saying?
 What do we do after death?
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Dying: Timing
< 1 day to 14 days
 Well nourished, hydrated, uninfected
patients live longer
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Goal Setting and Communication
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Confirm treatment goals
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Stop Rx unrelated to comfort
Progress notes
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“Patient is dying", not “Prognosis is poor".
Treat symptoms/signs as they arise
 Provide daily counseling and support to
family
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Communication
Open, honest rapport
 Diversity
 Spirituality
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Dying: Early
Bed Bound
 Loss of interest and/or ability to drink/eat
 Cognitive changes
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Increased sleep
Delirium
Dying: Mid
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Progressive decline in mental status
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Obtundation
Terminal Delirium
Death rattle
Dying: Late
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Coma
Fever
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Altered respiratory pattern
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Aspiration Pneumonia
Dehydration
Apnea
Hypopnea
Hyperpnea
Irregularity
Cheyne-Stokes
Mottled extremities
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Livido Mortis vs Livido Reticularis
Symptom Relief
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Pain
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Somatic
Bone
Neuropathic
Dyspnea
Secretions
Myoclonus
Seizures
Singultus
Pruritis
Anxiety
Insomnia
Delirium and Terminal Delirium
Spiritual Crisis and Distress
Goal Setting and Communication
Pain
Narcotics are safe and effective
 Multiple products and routes
 Bowel regimens
 Adjunctive therapies
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Pain: Somatic
WHO protocol
 Mild: Non-pharmacologic, Acetaminophen
 Moderate: NSAID, ASA
 Severe: Narcotics
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Fixed twice daily dosing
Break-through medication
Oral 3x parenteral
Equivalency charts
Treat anxiety, depression, psychiatric
illness
Bone Pain
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Bisphosphonates
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Prophylaxis
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Breast cancer and multiple myeloma most responsive
Lung, GI and prostate carcinomas less responsive
50-70% of patients get 30% pain reduction by a week for 12 wk
Repeat in a week for lack of response
Zoledronic acid 4mg IV over 15 minutes, cheaper, faster
Pamidronate 90mg IV administered over 2 hours, expensive, slower
Decreases skeletal-related events by 30% if known bone involvement
Toxicity
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Pamidronate and zoledronic acid identical.
Injection site reaction, Flu-like syndrome
Hypocalcemia, Scleritis less common
Renal dysfunction in long-term, or high dose use
Contraindicated CRF, Cr>0.5 over baseline or Cr>1.0 in CRI
Reduced dose CrCl <73.0 mg/dl, and slower infusion
Pain: Neuropathic
Gabapentin
 Tricyclics
 Narcotics
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Dypnea
Anxiolytics
 Moving Air
 Open doors and windows
 Mouth Care
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Secretions: Overview
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Death Rattle
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Turbulent air over pooled
Median time from onset to death 16 hr
 Two sub-types of Death Rattle proposed
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significance regarding treatment not
established
Type 1 = predominantly salivary secretions
Type 2 = predominantly bronchial secretions.
Secretions: Non-pharmacologic Rx
Postural drainage
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Position patient lateral or semi-prone
A minute or two of Trendelenburg
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Gentle oropharyngeal suctioning
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aspiration risk is increased.
often ineffective
Frequent suctioning disturbs patient and
visitors
Reduce fluid intake
Secretions: Pharmacologic Rx
Drug
Route Dose
Onset Cross Notes
BBB?
hyoscyamine hydro.
(Scopolamine Patch)
Patch
1 or more
patches
(about
1mg/3d)
12 hr
Yes
hyoscyamine sulph.
(Levsin)
PO
0.125 po
Q2-6 hr
30 min
No
Glycopyrrolate
(Robinul)
PO
1 mg/2-12 hr
30 min
No
SC, IV
.2 mg
1 min
Most potent
Erratic
absorption
PO, SL
1-10 gtt 1%
Q2-6 hr
1 mg
30 min
Yes
Cheap
Flexible
Most delirium
Atropine
IM, IV
1 min
Need short
term interim
meds 1st 12 hr
Myoclonus
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Focal or generalized
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sudden, brief, shock-like,
involuntary
Disrupts sleep, aggravates families
DDX
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Metabolic abnormalities
Medication Induced
Opioid-induced
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usually generalized, may be provoked by
a stimulus or voluntary movement.
Dystonia
Focal CNS
Seizure disorders.
Nocturnal Myoclonus
Sleep related
Treatment
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Underlying cause
Opioid induced: change opioid
Benodiazepine
Midazolam infusion
Dantrolene 50mg to 100mg daily
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Medications
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opioids,
anticonvulsants
tricyclics
SSRI's
contrast dye
anesthetics
penicillins
cephalosporins
imipenem
quinolones
cannabinoids
ifosfamide
Seizures
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Usual Care
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May require large doses of medication
Hiccups (Singultus) Pharmacologic
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Pharmacological
Anti-Psychotics:
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Chlorpromazine - the only FDA approved drug for hiccups.
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Haloperidol – 2.0-5.0 mg (IM/PO) loading then 1-4 mg po tid
Anti-Convulsants:
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Phenytoin - reportedly effective in patients with a CNS etiology
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25-50 mg po tid qid. IV 25-50 mg in 500-1000cc of NS over several hours
200 mg slow IV push followed by 300 mg po qd.
Valproic Acid and Carbamazepine :maybe
Miscellaneous:
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Baclofen - The only drug studied in a double blind randomized
controlled study for treatment of hiccups;
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5 mg po q8H did not eliminate hiccups but provided symptomatic relief in
some patients.
Metoclopramide - 10 mg po qid maybe for stomach distension
Nifedipine - 10 mg bid with gradual increase up to 20 mg tid maybe
Last ditch: amitriptyline, inhaled lidocaine, ketamine, edrophonium,
amantidine.
Hiccups (Singultus) Non-Pharmacologic
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Irritant
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Gargling with water
Biting a lemon
Swallowing sugar
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Vagal
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Produce a fright response
Vagal stimulation
Carotid massage
Valsalva maneuver
Interruption of phrenic
nerve transmission by
rubbing over the 5th
cervical vertebrae
Respiratory
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Sneezing
Coughing
Breath holding
Hyperventilation
Breath into a paper bag
Other
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Acupuncture
Diaphragmatic pacing
Surgical ablation of reflex
arc
Pruritis: Non-Pharmacologic
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Treat Causes
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Moisturizer
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Dermatologic
Metabolic
Hem/Onc
Drugs
Infection
Allergy
Psychogenic.
Xerosis
Cooling agents
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Calamine
Menthol in aqueous cream 0.5%-2%
Pruritis: Pharmacologic
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EMLA Cream
Antihistamines
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Steroids
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Inflammatory itching
Topical
Systemic for refractory cases
Aveeno
Cholestyramine
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Histamine mediated itching
Doxepin may work in selected cases
Cholestatic
Other
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Ondansetron,
Paroxetine
Naloxone
Anxiety
Address underlying causes
 Treat dyspnea
 Treat sleep deprivation
 Narcotic euphoria overlaps anxiolysis
 Address spiritual issues
 Benzodiazepines
 Other Drug Treatment
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Insomnia
Symptom Relief
 Treat Undiagnosed Sleep Disorders
 Sleep Hygiene
 Relaxation Techniques
 Sleep Restriction
 Cognitive Behavioral Therapy
 Stimulus Control Therapy
 There is no EBM on nightmares
 The usual drug therapies
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Delirium and Terminal Delirium
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Waxing and waning level of consciousness
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Non-pharmacologic Rx
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Reduce or increase sensory stimulation
Relatives and friends stay with patient
Frequent reorientation
Familiar objects
Haloperidol 0.5 to 2 mg po IV q 1 hour: EBM
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Hyperactive
Hypoactive
High-potency short-acting anti-psychotics=drug of choice
Underused
Benzodiazepines
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Second choice
“Paradoxical” worsening of delirium
Overused
Delirium and Terminal Delirium
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Other neuroleptics
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Chlorpromazine
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Probably comparable to haloperidol
Olanzapine is up and coming
Sedation is desired
Newer atypical antipsychotic
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May help
EMB scant
Perhaps with underlying dystonia or Parkinsons
Spirituality
Chaplain
 Diverse pastoral care
 Music therapy
 Communication
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Ethical Issues
“Truth-Telling”
 Family
 Euthanasia
 Hospice Resource Allocation
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Diversity and Ethnic Issues
Cultural Competency in questioning
 Awareness of beliefs
 Ritual
 Communication
 Staff education
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Hospice
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Use liberally
EPERC
Medical College of Wisconsin
 http://www.eperc.mcw.edu/
 Fast Facts are available for downloading
onto your PDA. Information and download
available at www.infingo.com/mninfo.htm

EPEC


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http://www.epec.net/EPEC/webpages/index.cfm
The EPEC Project, Northwestern University's
Feinberg School of Medicine
750 N Lake Shore Drive, Suite 601 Chicago, IL
60611
Tel. 312/503-3732, FAX: 312/503-5868 Email:
info@epec.net
The EPEC Project was supported from 1996-2003
with funding from The Robert Wood Johnson
Foundation.
Last modified 12/09/2005.
Summary
EMB for symptomatic relief at the end of
life is accumulating
 Many distressing symptoms can be
remitted
 Web-based resources for information are
readily available

Bibliography

Fast Facts and Concepts #109. Death rattle and oral secretions. Bickel K and Arnold
R. March 2004. End-of-Life Physician Education Resource Center
www.eperc.mcw.edu.
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DeMonaco D and Arnold R. Fast Facts and Concepts #114. Myoclonus. May 2004.
End-of-Life Physician Education Resource Center www.eperc.mcw.edu
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
.
Fast Facts and Concepts #104. Miller M and Arnold R. Insomnia: Non Pharmacological
Treatments. January 2004. End-of-Life Physician Education Resource Center
www.eperc.mcw.edu
Malhotra, S and Arnold R. MD Fast Facts and Concepts #88 . Nightmares. April 2003.
End-of-Life Physician Education Resource Center www.eperc.mcw.edu
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Fast Facts and Concepts #81 Hiccups. Farmer, C. January 2003. End-of-Life Physician
Education Resource Center www.eperc.mcw.edu
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Fast Facts and Concepts #37 Gunten CF, Ferris F. Pruritis. August, 2005. 2nd edition.
End-of-Life Palliative Education Resource Center www.eperc.mcw.edu
Bibliography
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Diagnosis and Management of terminal delirium. Fast Fact and Concept #1; 2nd
Edition, July 2005. End-of-Life Palliative Education Resource Center
www.eperc.mcw.edu
Syndrome of Imminent Death. Fast Fact and Concept #3; 2nd Edition, July 2005.
End-of-Life Palliative Education Resource Center www.eperc.mcw.edu
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Fast Facts and Concepts #60 Pharmacologic Management of Delirium; update on
newer agents. Earl Quijada, M.D. and J. Andrew Billings, M.D.. January, 2002. End-
of-Life Physician Education Resource Center www.eperc.mcw.edu

Weinstein E and Arnold A. Fast Facts and Concepts #113. Bisphosphonates for bone
pain. April 2004. End-of-Life Physician Education Resource Center
www.eperc.mcw.edu