Symptoms to expect in last hours
Two main roads to death:
Usual
(up to 90%)
- Lethargic → obtunded → comatose → death
Difficult
(don’t allow to happen!)
- Restless → confused → delirious → myclonus → seizures → comatose → death
Goal: patient should look comfortable, like peaceful sleep. People do move somewhat, and make some noise, so don’t medicate to supress all activity, but to achieve peaceful look.
Consult palliative care team if patient doesn’t settle with usual terminal care orders below
Managing symptoms in last hours
- Discontinue monitoring vital signs, pulse oximetry, blood glucose monitoring and labwork.
- Convert high flow oxygen to nasal prongs (titrate, do not switch abruptly) 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: oral sponge swabs dipped in water or diluted mouthwash Q2H and PRN to remove debris and keep mouth moist.
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 q1-2hrs prn
Upper airway secretions:
Glycopyrrolate 0.2mg s.c. q3hrs prn
Scopolamine 0.2mg s.c. q3hrs prn
Change position of patient
Fever:
Acetaminophen 650mg per rectum q4hrs prn
Titration
- if 3 or more PRNs in 24h for any symptom above, add regular scheduled dose or increase regular dose and titrate 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
- Explain the natural process of dying so family knows what to expect.
- 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
Our aim is to control all symptoms and enable the person to have meaningful life by being aware & sharing experiences with others. The intent and intensity of our therapy is aimed at relieving the symptom, not inducing sedation.
However, in the last 1-2 weeks of life, occasionally episodes occur where the disease induces states that are refractory to usual therapies and overwhelm consciousness, including:
- refractory agitated delirum,
- refractory dyspnea or pain,
- massive hemorrhage,
- status epilepticus,
- saddle embolus.
There is no chance for the patient to achieve benefits of being conscious through symptom control. Intent is restore calm to the patient through sedation. Intention is sedation to unconsciousness, not death. Patient dies from their illness and not sedation.
Consult palliative care in determining whether symptom refractory.
Consider: dexmedetomidine which has sedative, anti-anxiety, and analgesic properties and does not pose a risk of severe respiratory/circulator depression. Consult PC
Existential distress is not an appropriate indication. See Existential Distress in Manage for therapies.
Request for hastened death is not an appropriate use.
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 https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/vsa051.pdf
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.