Care in the Last Few Days of Life
Compassionate and medically appropriate care in the last few days of life can make a huge difference to a person's suffering in the last days and the experience of family and close friends. It is however in many case very hard to be completely certain that a person is in their last few days of life, especially in non-cancer patients with general medical co-morbidities. As a general rule it is often important to remain flexible, and at times, because of uncertainty, it is reasonable to give basic ward treatment (such as antibiotics) whilst also giving comfort relief medications (such as anxiolytics). Clear communication with family about the expected prognosis and about uncertainty is of paramount importance, as is anticipating potential symptoms and ensuring medication and carers are available to help alleviate those symptoms.
Common symptoms in dying patients
Common symptoms and signs in dying patients include:
- Restlessness and agitation
- Noisy, distressing breathing from respiratory secretions
- Nausea and vomiting
- Shortness of breath
Opioids are the mainstay for pain that occurs in dying patients. In general, lower doses are needed for the elderly. In cases where a person may not be imminently dying, then it is perhaps best to avoid morphine if the patient is known to have renal failure. Initial doses of analgesia for opioid naive patients are:
Morphine 5mg hourly SC PRN for pain
In opioid tolerant patients doses will need to be higher. If the patient had been on a longer term long-acting oral opioid, this should be converted into a continuous subcutaneous infusion at the equivalent analgesic dose.
If background analgesia in addition to breakthrough analgesia is needed, a resonable starting dose in an opioid naive patient would be 10mg of morphine over 24 hours, i.e.
Morphine 10mg via CSCI over 24 hours
Restlessness and Agitation
It is worthwhile looking for any easily reversible causes of agitation in a dying patient. For example, a distended bladder from urinary retention can cause significant distress. Both benzodiazepines and anti-psychotics can play a role in reducing agitation in dying patients. Benzodiazepines are often helpful for anxiety and restlessness and anti-psychotics are ideal for hallucinations or paranoia. For example:
Midazolam 2.5-5mg hourly SC PRN for anxiety or distress AND Haloperidol 1-2.5mg 2-hourly SC PRN for agitation or distress
In patients whom a background anxiolytic needs to be used, a reasonable starting dose of midazolam is 10mg over 24 hours, i.e.
Midazolam 10mg via CSCI over 24 hours
As a person dies and their swallowing becomes impaired, throat and respiratory secretions often build up and cause quite noisy breathing. This can be especially distressing to relatives sitting with their loved one. Anti-muscarinics can reduce these secretions, especially if started early. An example dosing schedule may be:
Hyoscine butylbromide 60mg via CSCI over 24 hours PLUS Hyoscine butylbromide 20mg 4-hourly SC PRN for noisy, distressing respirations
Nausea and Vomiting
For patients already on anti-emetics, it may be possible to convert this to a subcutaneous formulation.
Dopamine antagonists are reasonable first-line agents for PRN nausea, e.g.
Haloperidol 0.5-1.5mg 2-hourly PRN for nausea or vomiting
Shortness of breath
Dyspnoea often improves with opioids. Benzodiazepines may also help with with shortness of breath, especially when anxiety plays a role. Prescribing PRN medications such as the following may help:
Morphine 2.5-5mg hourly SC PRN AND/OR Midazolam 2.5-5mg horly SC PRN
The above opioid dose may need to be adjusted based on patient factors such as age, previous side effects, tolerance and renal function.
Often a continuous subcutaneous infusion (CSCI) containing medications such as opioids and benzodiazepines can be helpful in relieving symptoms. Exact medications and dosing will obvious vary based on what the patient needs and other patient factors such as previous opioid usage.
An example of an appropriate initial dose of a CSCI for an elderly opioid-naive patient who is suffering from pain and distress in the last days of life is shown below:
Morphine 10mg via CSCI over 24 hours PLUS Midazolam 10mg via CSCI over 24 hours
PRN medications should be prescribed in addition to any CSCI. If inadequate relief of suffering is achieved through a CSCI, the doses can be titrated up and medications in it modified.
Nutrition and Fluids
In the last few days of life, lack of nutrition and fluids can be a anxiety-provoking worry in family members of a dying patient. In general, it is appropriate to allow an awake patient to take sips of fluids and small mouthfuls of food if the patient requests it. As a patient becomes weaker or loses consciousness and can't take in anything orally, keeping the mouth moist can reduce thirst. In general, parenteral fluids are usually ineffective for thirst and may worsen distressing respiratory secretions, therefore these should be reserved for severe thirst refractory to optimal mouth care, or where oral route is lost before the desire to drink has reduced (e.g. due to an occluding oesophageal tumour). For patients who are on supplemental nutrition (e.g. via a PEG) it is usually appropriate to cease these.
Long-term medications (e.g. oral hypoglycaemic drugs) should usually be ceased unless they reduce symptoms (e.g. a GTN patch).
If stopping a medication could could serious symptomatic harm then an alternative may need to be found once the oral route is no longer available.
Some anti-convulsants can be given via CSCI (e.g. levetiracetam); if this is not the case, seizure risk may be minimized by giving midazolam 20mg over 24 hours via CSCI.
Knowing what to do with regards to insulin for patients with type I diabetes is difficult. One approach that can be used to reduce symptoms of diabetic ketoacidosis is to give half the previous total daily dose of insulin as a single daily dose of glargine insulin, checking blood glucose levels once daily, and modifying glargine insulin dose to maintain glucose levels between 6 and 15mmol/l.
Steroids should be continued if used for symptom control. Dexamethasone can be given subcutaneously (4mg dexamethasone ≈ 30mg oral prednisolone).
Anti-Parkinsonian medications should generally be continued until oral route lost. In the imminently dying, midazolam 10mg over 24 hours via CSCI can be used for rigidity and titrated up as neeed. If it is desirable to avoid midazolam’s sedating effects, alternatives include continuing existing medications via a PEG or NG (in hospital only).
Implanted Cardiac Defibrillators (ICDs)
If a patient has one, implanted cardiac defibrillators should be turned off if this has not already been done. Seek advice from a cardiologist regarding this. In urgent situations, a strong magnet placed on the chest over the defibrillator temporarily deactivates the defibrillator (once the magnet is removed, the defibrillator will be active again).
Place of care
When possible, asking patients and families about wishes regarding place of care at the end of life ahead of time allows plans and preparations to be made. Many patients wish to die outside of hospital in their homes. Good community palliative care teams can usually make this possible, although it is not uncommon for relatives to change their mind in the last few days of life due to the pressure and stress of caring for a bed-bound difficult to rouse family member. It is ideal for a palliative care inpatient unit to have capacity to admit dying patients at any time for such situations but not all hospices are able to provide this level of responsiveness. As in other specialties, local knowledge of what services are available is key.