General Points

Hospital Guidelines - Palliative Care
Key Notes on symptom control issues in Palliative Care
This page was last updated on 11 November, 2005
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Full Document
Nausea and Vomiting
Intestinal Obstruction
Respiratory Symptoms
Spinal Cord Compression
Superior vena caval obstruction (SVCO)
Management of the last days of life - incl terminal restlessness
Miscellaneous Symptoms
Use of steroids in palliative care
Indications for the use of a syringe driver

Management of the last days of life

This is a difficult time for all concerned. Professional carers may need a way of being able to acknowledge and share their feelings. The mutual support of working in a multi-professional team can be very important.
It may be hard to recognise when death is imminent but it is usually heralded by a more rapid deterioration in the patient’s general condition and the following:
  • Profound weakness with the patient bed-bound and drowsy for long periods.
  • Disorientated in time
  • Limited attention span of a few minutes
  • Disinterested in food and drink and the world around them
  • Too weak to swallow medication
If the approach of death is recognised, this allows the withdrawal of unnecessary treatments such as anti-hypertensives, appetite stimulants etc.. It also allows the family and in some instances the patient to prepare for death. It can be difficult to ask directly about the patient and family’s perceptions of how close death is, but if it is possible to do so, it allows for the most appropriate management plan to be negotiated. This will include looking at the preferred place of death and whether this is achievable with the resources (both professional and informal) available. The wishes of the patient may already be known to the primary care team and the family, but they should be checked out again as death approaches. Many patients and carers have unfinished business. This may be legal (drawing up a will), financial, interpersonal or spiritual. Be prepared to ask broad questions and help the family and patient to access the appropriate help from the appropriate ‘expert’.
Physical care in the last few days of life
  • Good regular mouth care to eliminate dry mouth and reduce the sensation of thirst. This may be something that some families like to be actively involved with.
  • Ensuring that appropriate pressure relieving mattresses are in place and their effectiveness regularly monitored.
  • Consider catheterisation, using convenes or pads to maintain dignity and avoid incontinence.
  • Only continue medication needed for symptom control, but ensure that the family is aware of why other medications have been stopped. Review the route of administration and plan ahead, so that an alternative route is available if the oral route becomes impossible.
  • Anticipate possible symptoms and ensure there is a means of addressing them quickly both in hours and out of hours. For instance, is the patient at risk of a fit? If so, can the family be taught to use rectal diazepam and is it in the house?
  • Patients are dying from their disease and not from lack of fluid or food. Artificial hydration of any sort does not usually contribute to a dying patient’s comfort. This needs to be sensitively explained to the carers and patient.

Terminal restlessness
Step one Treat reversible causes if possible Stat dose of midazolam sc
Step two Syringe driver with midazolam  
Step three Ask for help  

How people die lives on in the memory of those left behind’ (Dame Cecily Saunders). No matter how well pain and other symptoms are controlled, agitation and restlessness occur as a pre-terminal event in the final hours or days of life in about 10% of patients. Respiratory tract secretions can also accumulate in the final hours or days of life. This is more likely to happen with lung pathology, whether primary or secondary and those who have cardiac problems. Such secretions cause distress to the relatives and occasionally to the patient and may need to be actively managed.
Exclude treatable causes for agitation:

Urinary retention – palpable bladder?

Faecal impaction – loaded rectum?

Increased or under treated pain – has the patient had their usual analgesics? Is the syringe driver working?

Opioid toxicity – is there evidence of myoclonus, twitching, cognitive impairment including hallucinations?

Correct any treatable causes where possible and where the intervention is acceptable to the patient and family.
If opioid toxic, reduce the opioid dose by 50% and review the effect. Consider the use of haloperidol as outlined below.
Generalised agitation
Give a stat dose of midazolam 5mg subcutaneously. Repeat a 5mg dose after 15 minutes if necessary. After another 15 minutes give 10mg, if there was no or only a partial response to the initial two injections. A subcutaneous infusion via a syringe driver will need to be set up within the next two hours to ensure control is maintained, as midazolam has a very short half-life. Dose range will be between 20 –60mg over a 24-hour period. Ensure an adequate prn dose of midazolam 5-10mg is prescribed and available for use.
Agitation associated with visual hallucinations and/or paranoia.
Give a stat dose of haloperidol 5mg subcutaneously. This may have to be combined with midazolam 5mg to get the patient settled initially. A subcutaneous infusion via a syringe driver will need to be set up within the next four hours to ensure control is maintained. Use 10mg of haloperidol over 24hours.
Remember that open and honest communication may help avoid long term complications. Children, parents and grandparents may feel excluded in the last few days of life, and may need to be actively involved by the professionals. Specialist advice might be needed when young children are involved. Look for those members of the family at risk of an abnormal and prolonged grief reaction and organise appropriate support. It may be appropriate for such support to start before the death.