End of Life Care

Question 1

What are the five most common end of life symptoms.

Answer 1

Pain
Dyspnoea 
Respiratory secretions
Nausea 
Agitations

Question 2

What are the aims when managing pain in end of life care.

Answer 2

Optimising pain control
Ensure appropriate route
Ensure subcutaneous breakthrough available
- if opioid naive and renal function ok = 2mg subcutaneous morphine
- if on background opiate, breakthrough should be a sixth if daily requirement
Look out for non-verbal signs (grimacing, stiff when moved, groaning)

Question 3

What are the aims of managing dyspnoea in end of life care?

Answer 3

Ensure sats are ok, do they need oxygen for comfort
Reversible causes - tumour’s obstruction, anaemia, not related to cancer
Non-pharmacological - fresh air, fans
Pharmacological - opiates and maybe benzodiazepines
- if opioid naive and renal function ok, prescribe 2mg subcut morphine and midazolam

Question 4

What are the aims when managing respiratory tract secretions in end of life care?

Answer 4

Non-pharmacological
- positioning in bed, appropriate suctioning
Pharmacological
- hyoscine butylbromide 20mg subcutaneous bolus
- glycopyrrinium 200mcg subcutaneous

Question 5

What causes excessive respiratory tract secretions during end of life care?

Answer 5

The inability of the patient to handle and swallow salvia

Question 6

How is nausea managed during end of life care?

Answer 6

Subcut antiemetics - poor absorption from the GI tract

- levomeproazine (can go in a pump)

Question 7

What are the causes of nausea in end of life care?

Answer 7

Likely to be multifactorial

• uraemia
• biochemical disturbance
• constipation/obstruction
• anxiety

Question 8

What are the reversible causes of agitation in end of life care?

Answer 8

• pain
• shortness of breath
• nausea
• secretions
• urinary retention
• constipation
• drugs
• alcohol/drug/nicotine withdrawal

Question 9

What action should be taken in an agitated end of life patient, with no identifiable reversible cause?

Answer 9

STEPWISE

1) conscious sedation - still awake but more relaxed (lorazepam or low dose midazolam)
2) unconscious section - unable to be relaxed when awake, so ensure they have enough sleep
3) deep sedation - huh dose midazolam/levomepromazine/phenobarbitone

Question 10

What general comfort measures should be undertaken in patients during end of life care?

Answer 10

Regular mouth care
Pressure care
Subcut fluids
Support for the family