End of life care: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
*Weakness, fatigue, and functional decline | *[[Weakness]], fatigue, and functional decline | ||
**Increased risk of pressure ulcers | **Increased risk of pressure ulcers | ||
*Decreased oral intake | *Decreased oral intake | ||
*Neurologic changes | *Neurologic changes | ||
**Decreasing levels of consciousness leading to coma and death | **Decreasing levels of consciousness leading to [[coma]] and death | ||
**Terminal delirium confusion, restlessness, agitation, day-night reversal | **Terminal [[delirium]] confusion, restlessness, agitation, day-night reversal | ||
*Accumulation of upper airway secretions | *Accumulation of upper airway secretions | ||
**Decreased gag reflex and ability to swallow leads to gurgling, or rattling sounds with each breath | **Decreased gag reflex and ability to swallow leads to gurgling, or rattling sounds with each breath | ||
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==Management== | ==Management== | ||
*Pain and dyspnea | *Pain and dyspnea | ||
**Opioids are the mainstay of treatment | **[[Opioids]] are the mainstay of treatment | ||
**Choice of opioid based on provider preference, no trials to support one over another | **Choice of opioid based on provider preference, no trials to support one over another | ||
**Opioid naïve patients: | **Opioid naïve patients: | ||
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**Discontinue non-essential IV fluids or enteral feedings | **Discontinue non-essential IV fluids or enteral feedings | ||
**Position the patient on his or her side | **Position the patient on his or her side | ||
**Glycopyrrolate (0.2 mg SC q4-6hrs, or 0.2 to 0.4 mg PO q8hrs | **[[Glycopyrrolate]] (0.2 mg SC q4-6hrs, or 0.2 to 0.4 mg PO q8hrs | ||
***Generally preferred over atropine and scopolamine because of less central effects | ***Generally preferred over [[atropine]] and [[scopolamine]] because of less central effects | ||
*Delirium | *Delirium | ||
**[[Haloperidol]] 0.5 to 1 mg haloperidol (PO, IV, IM, or SC), repeat dose every 45 to 60 minutes titrated against symptoms | **[[Haloperidol]] 0.5 to 1 mg haloperidol (PO, IV, IM, or SC), repeat dose every 45 to 60 minutes titrated against symptoms | ||
**For patients with persistent agitated delirium, a single dose of [[lorazepam]] may be beneficial as an adjunct to haloperidol. | **For patients with persistent agitated delirium, a single dose of [[lorazepam]] may be beneficial as an adjunct to haloperidol. | ||
==Disposition== | ==Disposition== | ||
Revision as of 01:14, 27 January 2019
Background
- Despite widespread hospice services, many terminally ill patients visit the ED at the end of life (EOL)
- Up to one third of cancer patients visit the ED in the last 2 weeks of life [1]
Clinical Features
- Weakness, fatigue, and functional decline
- Increased risk of pressure ulcers
- Decreased oral intake
- Neurologic changes
- Accumulation of upper airway secretions
- Decreased gag reflex and ability to swallow leads to gurgling, or rattling sounds with each breath
- Incontinence of urine and/or stool
- Inability to close eyes
- Cachexia leads to loss of retro-obital fat pad
- Ophthalmic lubricants for dry eyes
Differential Diagnosis
Evaluation
Management
- Pain and dyspnea
- Opioids are the mainstay of treatment
- Choice of opioid based on provider preference, no trials to support one over another
- Opioid naïve patients:
- Consider starting doses of 1-2mg IV morphine or 0.2 to 0.4mg IV hydromorphone
- May safely redose in 10 minutes
- Opioid tolerant patients:
- Consider starting with 10% of total daily opioid dose
- Airway secretions
- The “death rattle” tend to be more distressing to family members than to the patients themselves
- Discontinue non-essential IV fluids or enteral feedings
- Position the patient on his or her side
- Glycopyrrolate (0.2 mg SC q4-6hrs, or 0.2 to 0.4 mg PO q8hrs
- Generally preferred over atropine and scopolamine because of less central effects
- Delirium
- Haloperidol 0.5 to 1 mg haloperidol (PO, IV, IM, or SC), repeat dose every 45 to 60 minutes titrated against symptoms
- For patients with persistent agitated delirium, a single dose of lorazepam may be beneficial as an adjunct to haloperidol.
Disposition
See Also
External Links
References
- ↑ Barbera L. Why do patients with cancer visit the emergency department near the end of life? Can Med Assoc J. 2010;182(6):563-568.