END OF LIFE CARE

Care in the last days of life.

Clinical Features

Clinical signs at of end of life include (should be considered in those with terminal conditions who have been gradually deteriorating):

  • Patient becomes bedbound and is increasingly drowsy or in a semi-conscious state
  • Minimal oral intake; patient not managing oral medication and only able to take sips of fluid
  • The patient’s condition is deteriorating rapidly (e.g. day by day or hour by hour)
  • Breathing becomes irregular +/- noisy (death rattle)
  • Changes in skin colour and/ or temperature
  • Limited attention span

Investigations

  • Exclude reversible problems (e.g. drug toxicity, infections, dehydration, biochemical abnormalities)
  • Before ordering a test, always ask ”will this test change my management plan or the outcome for the patient?”
  • It is important to weigh the benefit versus the burden in assessing an intervention, and/or management plan based on the clinical features exhibited by the patient

Management

General principles of medicine treatment

  • Focus on giving medication that will improve the patient’s quality of life
  • Treat symptoms of discomfort as in sections above
  • If the patient is unable to swallow choose an appropriate route to give necessary medications
    (e.g. via NG tube, parenteral or rectally)
  • Subcutaneous (SC) is recommended when the enteral route is not possible. It is preferred over
    IV and IM access due to its reduced trauma and pharmacokinetics
  • If repeated injections are anticipated or experienced, a butterfly needle can be inserted
    and used as a route for regular SC injections Consider prescribing medications pre-emptively
    (anticipatory) to combat developing symptoms
  • Morphine concentrations can vary depending on the preparation used; remember that SC
    morphine has twice the potency of oral morphine

Hydration and nutrition

  • Patients should eat and drink as they wish, and take sips of water as long as they are able
  • Families should be educated that it is normal for patients to lose their appetite, have a sense
    of thirst and stop feeding towards the end of life. They should not feed patients if they are no longer
    able to swallow as this may cause choking and distress
  • IV fluids at this stage will not prolong life or prevent thirst. Over-hydration is discouraged
    as it may contribute to distressing respiratory secretions or generalised oedema; good regular
    mouthcare is the best way to keep the patient comfortable
  • IV dextrose for calorie supplementation is unlikely to be of benefit
  • If there is a reduced level of consciousness, patients should not be fed due to the risk of
    aspiration.
  • Artificial nutrition is generally discouraged at the end of life

Supportive care

  • Keep the patient clean and dry
  • Regularly clean the mouth with a moist cloth wrapped round a spoon
  • Prevent and manage pressure sores appropriately
  • Manage any associated pain
  • The end of life is an emotional time for all involved and requires health care professionals to be considerate and compassionate. Take time to listen to the concerns of the patient and their family; break bad news sensitively
  • Encourage the family to be present, holding a hand or talking to the patient even if there is no
    visible response; the patient may be able to hear even if they cannot respond
  • Consider spiritual support
  • Consider the best place of death for the patient and their family; would discharging them to go
    home be best?