Care in the Last Few Days of Life
Back-link: Palliative Wiki

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 his 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:
  • Pain
  • Restlessness and agitation
  • Noisy, distressing breathing from respiratory secretions
  • Nausea and vomiting
  • Shortness of breath

Pain

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 reasonable 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


Respiratory Secretions

As a person dies and his 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-muscarinic agents 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.