The terminal phase

Question 1

Describe the management of patients imminently dying who develop the death rattle

Answer 1

Exclude acute pulmonary oedema which is treated with furosemide

Hyoscine hydrobromide or hyoscine butylbromide (used in crampy abdominal pain as well)

Question 2

Describe some of the effects of hyoscine hydrobromide

Answer 2

Very dry mouth (can cause distress)

Sedation and confusion

Question 3

Describe alternatives to hyoscine hydrobromide (e.g. conscious and less severe respiratory secretions)

Answer 3

Transdermal patch (e.g. Scopaderm) 
Sublingual tablets (Kwells) 

(If not relieved) Glycopyronium bromide
Hyoscine butylbromide

(If RR > 20) Reduced by diamorphine

Tip bed 30 degrees and heads up

(If patient distressed) Midazolam

Question 4

State some causes of reversible terminal agitation

Answer 4

Pain 
Urinary retension 
Full rectum 
Nausea
Cerebral irritability 
Anxiety and fear 
Side effect of medication

Question 5

Describe the management of cerebral oedema in the terminal phase

Answer 5

Generous doses of opioids with NSAIDs and midazolam

Avoid drugs that lower seizure threshold (e.g. levomepromazine)

Question 6

Describe the management of irreversible terminal agitaiton

Answer 6

Midazolam or Clonazepam

(If patient still distressed) Add other medication (e.g. levomepromazine, haloperidol, phenobarbital)

(If syringe driver not available) Alternative phenothiazines with/without benzodiazepines

Question 7

Explain the role of Liverpool Care Pathway

Answer 7

Template for healthcare professionals in managing the dying patient

Three sections: initial assessment and care; on-going care; care of family and carers after death of patient

Question 8

Describe how patients are diagnosed as dying?

Answer 8

Multi-disciplinary team agreement

(In cancer patients with deterioration, 2 of the 4 must apply) Bed-bound; semi-comatose; only able to take sips of fluid; unable to take tablets

Question 9

Briefly describe the 3 parts of Liverpool Care Pathway

Answer 9

Section 1 Initial assessment and care: identifies key goals that should be achieved and are based on guidelines on regarding management in terminal phase

Section 2 On-going care of the dying patient: Looks at MDT approach and actions if certain problems should occur (e.g. pain, agitation, respiratory tract secretions, nausea and vomiting)

Section 3 Care of family and carers after death: Includes certification of death , any special needs support

Question 10

Describe the review of medication during terminal phase

Answer 10

Comfort is priority; unnecessary medication stopped

Diabetes can be managed by short acting insulin

Question 11

Describe the route of administration during the terminal phase

Answer 11

Intramuscular should be avoided

Buccal medicines (keep mouth moist)

Rectal

Topical (e.g. fentanyl) should be avoided as it may take too long

Question 12

State some common problems in the last 48 hrs of life

Answer 12

Noisy, moist breathing 
Pain 
Restlessness/agitation 
Breathlessness 
Nausea/vomiting 
Myoclonic twitching