Although benzodiazepines may help treat anxiousness or agitation in the last hours or days of life, use across longer time frames should be avoided in the treatment of delirium or agitation because they may cause or exacerbate a range of problems including: 98,100,101 • Cognitive impairment • Rebound insomnia (i.e., if taken as needed, patients sleep worse on the nights that they omit it) • Risk of falls • Paradoxical agitation • Physical dependence with regular use 102 • Aspiration and its consequences Antipsychotic medications, while of potential utility in patients with severe or uncontrollable delirium or agitation, should be avoided until other reasonable medications have been tried because of their relatively high risk of side effects and adverse events, including possible death. In June 2008, the US Food and Drug Administration (FDA) determined that both conventional and atypical antipsychotics increase the risk of death in elderly patients, and reiterated that antipsychotics are not indicated for the treatment of dementia-related psychosis. 103 Initiation of any medication for delirium or agitation should be at the lowest possible dose, with slow titration upwards if needed to the lowest effective dose. Patients must be monitored closely for both adverse effects and drug-drug interactions. If a medication is demonstrated to be effective, the patient should be reassessed frequently, since delirium or agitation symptoms are inherently unstable and subject to remission. Constipation Constipation is common at the end of life (because of low oral intake of food and fluids and the adverse effects of opioids) and should be closely managed because it can lead to pain, vomiting, restlessness, and delirium. Prevention generally involves a stimulant laxative (e.g., senna) with a stool softener (e.g., docusate or polyethylene glycol). If constipation does not resolve with these measures, stronger laxatives, suppositories, or enemas are indicated. Methylnaltrexone, naldemedine, and naloxegol can be used to treat opioid-related constipation that does not respond to traditional preventive or treatment regimens. Caring for a Person Near Death: Tips for Family Caregivers 104 • Continue to talk to the person and say the things you need or want to say. Remember that the person may be able to hear, even when not able to respond • Allow the person to sleep as much as he or she wishes • Reposition the person if it makes him or her more comfortable • Moisten the person’s mouth with a damp cloth • If the person has a fever or is hot, apply a cool cloth to the forehead
• Give medications as ordered to decrease symptoms such as anxiety, restlessness, agitation or moist breathing • Keep a light on in the room, it may be comforting • Play the person’s favorite music softly • Encourage visitors to identify themselves when talking to the person • Keep things calm in the environment • Open a window or use a fan in the room if the person is having trouble breathing • Continue to touch and stay close to your loved one Ethical Considerations A potential barrier to good pain management at the end of life is the misconception on the part of providers, family members, or both, that an escalation of pain medications or other palliative therapies will unethically hasten or cause death. Although ethical and legal consensus upholds the appropriateness of withdrawing unwanted or unhelpful therapies to avoid the prolongation of the dying process and the administration of medications with the intent of relieving suffering, such concerns may mitigate optimal administration of therapies. 105 When providers administer pain medications and other palliative therapies to a dying patient, the intent should explicitly be on relief of symptoms, and communication with the family must stress this goal, even if the possibility exists that such treatments could hasten death. 84 The doctrine of double effect draws a clear distinction between the aggressive palliation of pain with the intent to relieve suffering and the active and purposeful hastening of death. The doctrine asserts that the alleviation of pain is ethically justifiable as long as the caregiver’s primary intent is alleviating suffering. 39 (The doctrine of double effect holds that an act that might have a good or bad effect is ethical if the nature of the act is morally good or neutral and the intent of the act is good even if there is potential for bad effect.) 39 Health-care providers should communicate this strategy with patient and families and document the rationale for any dose escalation used for the alleviation of pain. Contrary to fears among patient and their families, research suggests that aggressive pain management at the end of life does not necessarily shorten life. In fact, pain management may be life- prolonging by decreasing the systemic effects of uncontrolled pain that can compromise vital organ function. 106 If a patient experiences intense pain, discomfort or other undesirable states at the end of life despite the best efforts of pain management providers, palliative sedation (also known as terminal, continuous, controlled, or deep-sleep sedation) is an option. 84 Palliative sedation is the intentional sedation of a patient suffering uncontrollable refractory symptoms in the last days of life to the point of almost, or complete, unconsciousness and maintaining sedation until death—but not intentionally causing death. 107
Although palliative sedation may bring intolerable suffering to an end and allow people to die peacefully, it nonetheless can be challenging to put into practice and has been criticized as “slow euthanasia.” 93 Acknowledging the inherently complex and subjective nature of decisions about palliative sedation, guidelines have nonetheless been developed to help guide responsible use of this alternative. Many guidelines state that palliative sedation should only be considered when: 94,108 • The patient is terminally ill • Death is expected within hours or days • The patient is suffering acute symptoms unresponsive to therapy • Consent is obtained from the patient or his/ her proxy • The withdrawal of food and water is discussed • Families are informed that the patient will likely not regain consciousness and will die • Causing death is not the intention even though it may not be possible to achieve adequate symptom control except at the risk of shortening the patient’s life The degree to which palliative sedation is used, and the manner in which it is used, must, in the end, be a matter of clinical judgment on the part of individual physicians. Palliative/End-of-Life Care Conclusions Compassionate care for patients who are dying requires clinicians to employ the full range of their therapeutic skills to holistically care for the physical, psychological, and emotional needs of both their patients and loved ones. This is a time when diagnostic skills and medical knowledge may be less important that emotional intelligence and communication skills. It may also entail a shift away from previous goals of aggressive treatment with advanced medical technology, and toward a realistic assessment of what such technology can actually provide in terms of comfort, dignity, and peace of mind at the end of life. Ongoing pain assessment is critical in order to detect changes in pain such as the development of painful bone metastasis, resolution of treatable causes such as infections, or worsened neuropathic or visceral pain due to tumor growth. Careful refinement of pain management regimens is often required at the end of life and may include changes in the route of analgesics if patients can no longer take oral medications, the need to rotate opioids, or the addition of adjunctive or integrative therapies. Clinicians should seek expert consultation from pain services or palliative care teams for complex cases or when pain appears to be refractory to all efforts. Early referral to hospice care may allow time for a carefully planned pain regimen to ensure comfort at the end of life. The other symptoms that can accompany the end of life, such as dyspnea, agitation, delirium, and anxiety, each need to be carefully assessed and treated with coordinated interventions.
16
Powered by FlippingBook