End of life care


  • 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 
    • Decreasing levels of consciousness leading to coma and death
    • Terminal delirium confusion, restlessness, agitation, day-night reversal 
  • 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



  • 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
  • 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.


See Also

External Links


  1. 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.