Last days and hours, death and afterwards

Use Terminal Care Orders, form PHC331.

Symptoms to expect in last hours

Two main roads to death:

(up to 90%)

  • Lethargic → obtunded → comatose → death

(don’t allow to happen!)

  • Restless → confused → delirious → myclonus → seizures → comatose → death

Consult palliative care team if patient doesn’t settle with usual terminal care orders, form PHC331.

Managing symptoms in last hours

  • Discontinue monitoring vital signs, pulse oximetry, blood glucose monitoring and labwork.
  • Convert high flow oxygen to nasal prongs and use opioids to manage dyspnea
  • Stop IV fluids as may increase pulmonary congestion. If removal of fluids signals abandonment to family reduce fluid to 50ml/hour.
  • Provide frequent mouth care.

Discomfort, pain, dyspnea:

  • For patient who has not received opioid in past 3 days: Hydromorphone 0.25-0.5mg sc q1hr prn
  • For patient who has received opioid in past 3 days: Continue the same order if it is currently a sc opioid. Rotate opioid to sc if currently oral (see Opioid calculations)

Confusion and/or agitation:
Methotrimeprazine 2.5-5mg sc q4hrs prn

Upper airway secretions:
Glycopyrrolate 0.2mg s.c. q3hrs prn
Scopolamine 0.2mg s.c. q3hrs prn
Change position of patient

Acetaminophen 650mg per rectum q4hrs prn

Terminal delirium: do not allow the patient to remain agitated. See manage Confusion/delirium: Drugs – Agitated delirium

Natural process of dying

Good article on the natural process of dying can be read online here, or downloaded in pdf format.

Supporting and managing the family

  • Review patient status for symptoms that aren’t controlled
  • Gather information about family perception of patient’s comfort
  • Review goals of care and irreversibility of unfolding events, particularly if taking longer than family expects
  • Ask family how they’re doing, and watch for signs of intense anxiety or distress, if found, social work/pastoral care should be alerted

Continuous Palliative Sedation Therapy

  • Refractory and intolerable suffering in the last 1-2 weeks of life
  • Aim of sedation is to relieve the suffering, does not hasten death
  • Usually for agitated delirium, refractory dyspnea or pain
  • Rarely needed when access to quality palliative care is available
  • Involve palliative care in decision-making around refractory symptoms

At time of death

  • Shift the focus of care to family and caregivers
  • Make the space and time for cultural and religious rites
  • If you know the patient, take some time yourself to review what has happened and say goodbye

Talk tip: ask the family, “How were his/her final moments?” “How are you feeling?” “Do you have any questions?”

After death

Death Certificate
Use the helpful handbook from BC Vital Statistics

Phone call or note
Much appreciated by family, especially if MD not there at time of death. Ask how they are doing and if they have further questions.

Talk tip: this might be the family’s first experience with a death. Validate that what they are seeing is a natural part of the dying process.

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