Managing Changes in the Patient's Condition during the Final Days and Hours
| Changes in the Patient's Condition | Potential Complication | Family's Possible Reaction and Concern | Advice and Intervention |
|---|---|---|---|
| Profound fatigue | Bedbound with development of pressure ulcers that are prone to infection, malodor, and pain, and joint pain | Pt is lazy and giving up. | Reassure family and caregivers that terminal fatigue will not respond to interventions and should not be resisted. Use an air mattress if necessary. |
| Anorexia | None | Pt is giving up; pt will suffer from hunger and will starve to death. | Reassure family and caregivers that the pt is not eating because he or she is dying; not eating at the end of life does not cause suffering or death. Forced feeding, whether oral, parenteral, or enteral, does not reduce symptoms or prolong life. |
| Dehydration | Dry mucosal membranes (see below) | Pt will suffer from thirst and die of dehydration. | Reassure family and caregivers that dehydration at the end of life does not cause suffering because pts lose consciousness before any symptom distress. IV hydration can worsen symptoms of dyspnea by pulmonary edema and peripheral edema as well as prolong dying process. |
| Dysphagia | Inability to swallow oral medications needed for palliative care | Do not force oral intake. Discontinue unnecessary medications that may have been continued, including antibiotics, diuretics, antidepressants, and laxatives. If swallowing pills is difficult, convert essential medications (analgesics, antiemetics, anxiolytics, and psychotropics) to oral solutions, buccal, sublingual, or rectal administration. | |
| “Death rattle”—noisy breathing | Pt is choking and suffocating. | Reassure the family and caregivers that this is caused by secretions in the oropharynx and the pt is not choking. Reduce secretions with scopolamine (0.2-0.4 mg SC q4h or 1-3 patches q3d). Reposition pt to permit drainage of secretions. Do not suction. Suction can cause pt and family discomfort and is usually ineffective. | |
| Apnea, Cheyne-Stokes respirations, dyspnea | Pt is suffocating. | Reassure family and caregivers that unconscious pts do not experience suffocation or air hunger. Apneic episodes are frequently a premorbid change. Opioids or anxiolytics may be used for dyspnea. Oxygen is unlikely to relieve dyspneic symptoms and may prolong the dying process. | |
| Urinary or fecal incontinence | Skin breakdown if days until death Potential transmission of infectious agents to caregivers | Pt is dirty, malodorous, and physically repellent. | Remind family and caregivers to use universal precautions. Frequent changes of bedclothes and bedding. Use diapers, urinary catheter, or rectal tube if diarrhea or high urine output. |
| Agitation or delirium | Day/night reversal | Pt is in horrible pain and going to have a horrible death. | Reassure family and caregivers that agitation and delirium do not necessarily connote physical pain. |
| Hurt self or caregivers | Depending on the prognosis and goals of treatment, consider evaluating for causes of delirium and modify medications. Manage symptoms with haloperidol, chlorpromazine, diazepam, or midazolam. | ||
| Dry mucosal membranes | Cracked lips, mouth sores, and candidiasis can also cause pain. Odor | Pt may be malodorous, physically repellent. | Use baking soda mouthwash or saliva preparation q15-30min. Use topical nystatin for candidiasis. Coat lips and nasal mucosa with petroleum jelly q60-90min. Use ophthalmic lubricants q4h or artificial tears q30min. |