● By decreasing urine output urinary incontinence or difficulties of using a bedpan or commode are reduced ● Reduced gastrointestinal secretions may reduce nausea and vomiting ● In cancer patients, pain may be improved by a reduction in tumor edema ● Reduction in oropharyngeal and pulmonary secretions may lead to reduced airway congestion and diminished pooling of secretions the patient cannot clear on his or her own added if a vestibular component of nausea is present or suspected. Synthetic cannabinoid agents (e.g., dronabinol) and medical marijuana (in states where it is approved for medical use) may be considered as second-line agents for nausea control, although they should be used with caution because they can provoke delirium and dosing of medical marijuana may be imprecise. Vomiting can occur due to mechanical bowel obstruction, which is common with pelvic and gastrointestinal cancers. Management with an antiemetic (e.g., haloperidol) as well as corticosteroids and analgesics is recommended. 90 increased difficulty breathing, restlessness, and grunting are clinical signs of dyspnea. Opioids are first-line agents for treating dyspnea at the end of life. 36 Opioids help reduce the sense of “air hunger” and, when administered at appropriate doses, do not compromise respiratory status or hasten dying. 92 Opioids should be selected and administered based on patient’s comorbidities, previous opioid exposure, and ease of administration (see Table 8 for initial doses). Morphine and oxycodone are available in concentrated forms and sublingual formulations, which allow rapid administration regardless of a patient’s level of wakefulness or swallowing ability.
of specific foods (such as sweet custards or ice cream) which are well-tolerated. The forced administration of nutrients, either parenterally or through a nasogastric or gastrostomy tube, has little or no benefit to most patients in the last days or weeks of life, and the placement or continuation of an intravenous line or enteral feeding tube can be burdensome. Enteral feeding tubes used during the terminal phase of illness are often more useful as a means of administering medications than nutrients. Concerns about adequate hydration are frequently misplaced. Relative dehydration can be beneficial during the terminal phase for the following reasons: 39 Nausea and vomiting Multiple neurotransmitter pathways in the brain and gastrointestinal tract mediate nausea and vomiting, both of which are common in EOL care. Some therapies for nausea (e.g., haloperidol, risperidone, metoclopramide, and prochlorperazine) target dopaminergic pathways to inhibit receptors in the brain’s chemoreceptor trigger zone. 89 Serotonin 5-HT 3 receptor antagonists such as ondansetron and palonosetron have been used to treat chemotherapy and radiation therapy related nausea, although in studies of patients with EOL-related nausea, these agents have not been shown superior to older dopaminergic agents. 36 Anticholinergic medications such as meclizine or transdermal scopolamine can be Dyspnea Dyspnea is common among patients at the end of life and is associated with many diseases or conditions including end-stage pulmonary and cardiac disease, cancers, cerebrovascular disease, and dementia. A number of mechanisms can be involved in dyspnea including pneumonia, airway hyperreactivity, pulmonary edema, pleural effusions, and simple deconditioning. Assessing the severity of dyspnea can be challenging because most dyspnea scales rely on patient self-report, although the Respiratory Distress Observation Scale (eight variables, 0-16 score) is based solely on observers’ clinical assessments. 91 Regardless of a patient’s measured oxygen saturation, tachypnea,
Table 8. Initial opioid doses for dyspnea or pain in opioid-naïve EOL patients 36
Medication
Oral dose
IV or subcutaneous dose
Initial dosing frequency
Fentanyl
Transmucosal 100-200 mcg 25-100 mcg
Every 2-3 hrs. Every 3-4 hrs. Every 3-4 hrs. Every 3-4 hrs.
Hydromorphone 2-4 mg
0.5-2 mg
Morphine
2.5-10 mg 2.5-10 mg
2-10 mg
Oxycodone
NA
Delirium and agitation Delirium and agitation are commonly associated with dementia, but may also occur in patients without diagnosed dementia due to physiological or psychological changes at the end of life. Manifestations can include calling out, screaming, verbal and physical aggression, agitation, apathy,
hostility, sexual disinhibition, defiance, wandering, intrusiveness, repetitive behavior and/or vocalizations, hoarding, nocturnal restlessness, psychosis (hallucinations or delusions), emotional lability, and paranoid behaviors. 93,94
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Book Code: CA23CME
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