End of life care
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.