___________________________________________ Palliative Care and Pain Management at the End of Life
INTERVENTIONS FOR PATIENTS WHO ARE IMMINENTLY DYING
Intensify ongoing care. Try to ensure privacy (if not at home, arrange for private room if possible). Discontinue diagnostic tests. Reposition for comfort as appropriate. Avoid unnecessary needle sticks. Provide mouth care (e.g., hydrogen peroxide/water solution). Treat for urinary retention and fecal impaction. Ensure access to medication even when oral route is not available.
Prepare to meet request for organ donation and autopsy. Allow patient and family uninterrupted time together. Ensure the patient and family understand the signs and symptoms of imminent death and are supported through the dying process. Offer anticipatory bereavement support. Provide support to children and grandchildren. Encourage visits by children if consistent with family values. Support culturally meaningful rituals. Facilitate around-the-clock family presence. Ensure that caregivers understand and will honor advance directives. Provide respectful space for families. Facilitate closure. Source: [310] Table 24
TREATMENT OF EXCESSIVE RESPIRATORY SECRETIONS CAUSING “DEATH RATTLE”
Drug
Dose
Scopolamine (transdermal patch)
One (1.5-mg) patch applied behind the ear and changed every 72 hours Onset of action may be delayed several hours, so other anticholinergic treatment should be provided until effective. 0.2–0.4 mg SC, repeat at 30 minutes, then every 4 to 6 hours, as needed; or 0.6–1.2 mg/day CSCI 0.4 mg SC, repeat at 30 minutes, then every 2 to 4 hours, as needed; or 0.6–1.2 mg/day CSCI
Glycopyrrolate
Hyoscyamine
Atropine
0.4–0.8 mg SC, repeat every 2 to 4 hours
agitation) [214]. Some evidence suggests that treatment is more effective when given earlier; however, if the patient is alert, the dryness of the mouth and throat caused by these medications can be distressful. Repositioning the patient to one side or the other or in the semiprone position may reduce the sound. Oropharyngeal suctioning is not only often ineffective but also may disturb the patient or cause further distress for the family. Therefore, it is not recommended. Terminal delirium occurs before death in 50% to 90% of patients. It is associated with shorter survival and complicates symptom assessment, communication, and decision making. It can be extremely distressing to caregivers and healthcare professionals alike [430]. Safety measures include protecting CSCI = continuous subcutaneous infusion, SC = subcutaneously. Source: [206]
Table 25
patients from accidents or self-injury. Reorientation strategies are of little use during the final hours of life. Education and support for families witnessing a loved one’s delirium are war- ranted [430]. There are few randomized controlled trials on the management of terminal delirium. Agents that can be used to manage delirium include haloperidol, which is frequently the first choice for its relatively quick action [206; 430]. Other drugs may include olanzapine, chlorpromazine, levomepromazine, and benzodiazepines [206; 430]. For terminal delirium associ- ated with agitation, benzodiazepines, including clonazepam, midazolam, diazepam, and lorazepam may be helpful [206; 227; 430]. Depending on which drug is used, administration may be intravenous, subcutaneous, or rectal, and the dose can be titrated until effective.
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MDCA1525
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