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

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

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.

See Also

• Goals of care
• Delivering bad news