Presentation on common symptoms in palliative patients in terminal stage and regarding its management (2015)

1. by Dr. Azhad Ahmed

2. Terminal Care
 Terminal care refers to care given during the last phase
of a person’s illness.
 Needs a lot of palliative care skill to fulfil the wishes of
the patient and those close to them.
 Patients usually have a rapidly changing clinical
condition and also require psychological care.

3. Why Terminal Care?
 Nature of terminal phase and subsequent death have
consequences for the bereaved.
 Allows patient to die with dignity in comfort, and in
the place of their wish.

4. Terminal Care
 Physical symptoms
 Psychosocial needs
 Nursing care
 Comfort care kit, palliative sedation

5. Physical assessment 1
 Pain
 Shortness of breath
 Nausea/Vomiting
 Agitation/Restlessness/Confusion
 Myoclonus and epilepsy
 Noisy breathing
 Urinary retention or incontinence

6. Physical assessment 2
 Constipation
 Pressure areas/skin care
 Dry mouth
 Difficulty in swallowing
 Reversible complications/co-morbidities

7. Pain
 Pain – it is important to note that even a semi-
conscious/uncommunicative patient can be in pain.
New pains could occur in the last 48 hours.
 Parenteral or alternate routes of administration of
drugs may need to be planned.
 Converting oral morphine to subcutaneous route
would be helpful.

8. Pain
 Inj. Morphine 2.5mg s.c. can be kept standby.
 For those already on opioids, equivalent doses for s.c.
administration can be given.
 Alternately, per-rectal administration of morphine can
be given. Per-rectal administration of
Paracetamol/NSAID suppositories are also an option.

9. Shortness of Breath
 Can be due to involvement of the lungs in primary
disease.
 Alternately can be due to anxiety, anaemia, infection,
asthenia or heart failure.
 Non-pharmacological measures like fans can be used.
 Opioids can be kept standby. Inj. Morphine 2.5mg s.c.
or per-rectally can be given if needed.

10. Nausea and Vomiting
 Positioning of the patient would be useful to prevent
aspiration.
 Antiemetics like Metoclopramide or Haloperidol can
be given s.c. or by continuous infusion using a syringe
driver.
 Metoclopramide 10mg s.c. prn/tds. Continuous
infusion doses of 30 – 120 mg/day can be given.

11. Nausea and Vomiting 2
 Inj. Haloperidol 5-20 mg/day in divided s.c. doses or
via syringe driver.

12. Restlessness/Agitation/Confusion
 Confusion is common in advanced illnesses
 Occurs upto 75% in the last days of illness
 Symptoms include drowsiness, poor concentration,
disorientation, poor short-term memory,
inappropriate behaviour.
 Misperceptions, delusions of hallucinations can occur.

13. Restlessness/Agitation/Confusion
 Rarely severe agitation or aggression may occur.
 Warning signs: emotional unease or anguish,
fluctuating disorientation, visual hallucinations,
paranoid ideas.

14. Restlessness/Agitation/Confusion
 Management would be to:
 Keep the patient safe
 Treat reversible causes
 Ensure patient is in a suitable environment
 Acknowldge the distress and fears of the patient and
give reassurances where possible

15. Restlessness/Agitation/Confusion
 Reversible causes to look for include:
 Uncontrolled pain
 Full bladder / Constipation
 Discomfort due to immobility
 Dyspnoea / Hypoxia
 Brain metastasis
 Mental/Emotional causes
 Drugs
 Biochemical causes (liver/renal failure, hypercalcemia)

16.  Management:
 Inj. Haloperidol: loading dose 2-5 mg, daily dose 5-10 mg
 Inj. Midazolam: loading dose 2-5mg, daily dose 5-30 mg
(drug of choice for anxiety/anguish)
 Diazepam oral/rectal: loading dose 2-10mg, daily dose 6-
20 mg.
 Alternately intermittent dose of Lorazepam starting at
1mg can be given. [uptodate.com]

17. Myoclonus
 Myoclonic jerks can occur in terminally ill patients.
 Can be due to electrolyte abnormalities, disease itself,
or drugs (strong opioids, anticholinergics).
 Consider reducing or stopping drugs where possible.

18. Myoclonus
 Diazepam: pr/oral, 5-10mg repeated every hour, then
10-20mg at night for prevention.
 Midazolam s.c., 2.5 – 5mg repeated every hour; 10-
30mg/24hrs infusion.

19. Epilepsy
 Control of epilepsy would require first-aid measures
(turning to the side if possible, supplemental oxygen if
available).
 If already on oral medications, alternate routes of
administration may be used.
 Sedatives can be added to existing medications.

20. Epilepsy
 Diazepam: pr, 5mg stat. Can be repeated after 15
minutes.
 Midazolam sc 2.5 – 5mg (0.1-0.2mg/kg) repeated every
hour; 10-30mg/24hrs infusion.
 For refractory seizures: Clonazepam 0.25 – 0.5 mg
po/ng bd/tds. Alternately Phenytoin 300mg om. OR
Levetiracetam (Keppra) 500mg bd. Hospice or
hospitalisation can be considered.

21. Noisy breathing
 Common in the terminal phase.
 No evidence to suggest that it disturbs the patient, but
maybe distressing to the relatives or caregivers.
 Non-pharmacological measures:
 Position on the side or on semi-prone position.
 Good mouth care.
 Stop or reduce parenteral fluids to <500ml/day.

22. Noisy breathing
 It is important to explain to the family that patient is
not starving or choking to death.
 Pharmacological:
 Atropine 1% eye drops 1-2 drops every 4-6 hours.
 Hyoscine 20mg sc and continuous infusion 40-
120mg/day.

23. Urinary retention / Constipation
 Urinary retention can be due to disease (prostate),
drugs or constipation.
 Bed-side commode or diapers can be considered.
Cathetrisation may be required.
 Drugs like anticholinergics may need to be stopped.
 Enema and suppositories can be used to treat
constipation.

24. Pressure sores
 Can be relieved by use of appropriate mattresses.
 Air/foam mattresses.
 Static air filled/fluid-filled mattresses.
 Work by distributing the pressure over a large area.

25. Psychosocial needs

26. Psychosocial needs
 Need to look for:
 Fear - of the diagnosis, mode of death, drug side effects
 Guilt – becoming a burden, past experiences
 Anger – loss of dignity, missed opportunities, loss of
independence
 Uncertainty – spiritual questions, prognosis, future of
the family
 Depression

27. Needs of the family
 Assessment of physical, financial and social needs of
the family may need to be done.
 Should have access to palliative care professionals, 24-
hours for advise/care.
 May need training to enable then to contibute to
patient’s care.

28. Artificial hydration
 Family members may think patient will die hungry.
 May notice that patient’s mouth and lips are dry.
 Needs discussion of Pros and Cons with family. Potential
harm from fluid overload or use of invasive cannulas
should be discussed. Patient would require hospitalisation
if family wants artificial nutrition.
 Hydration can be done subcutaneously in a home care
setting with Normal saline 0.9%, 500ml per day.

29. Nursing care
 Terminal care may involve care of wounds/pressure
sores with appropriate dressing.
 Patients may have feeding tube or catheters in place
which require care.
 Fall prevention by environment or behavioural change
may be required.

30. Palliative sedation
 Refers to administration of sedative medications to
reduce conciousness to render intolerable and
refratory suffering tolerable.
 Aim being to relieve symptoms and not to shorten life
in a patient who is imminently dying (considered as 14
days).
 Indications: Agitated Delerium, Dyspnoea, Pain,
Convulsions, Emergencies like massive haemorrhage
or stridor

31. Palliative sedation
 Options include conscious sedation vs deep sedation.
 Medications:
 Inj. Midazolam 1-2.5 mg sc/iv stat and continuous
infusion 0.5-2 mg/hr, with dose titrated to achieve
desired level of sedation.
 Inj. Phenobarbitone 200mg iv/sc bolus and continuous
infusion 600mg/day (600-1600mg/day).

32. Comfort care kit
 Useful to treat terminal symptoms in home care
setting.
 Has numbered medications, with instructions on
when and how to use.
 Medications and routes of administration tailored for
ease of use.
 These include: Paracetamol suppository, Morphine
(per-rectal), Haloperodol (sublingual), Lorazepam
(sublingual), Atropine eye drops (sublingual).

33. References
 The Bedside Palliative Medicine Handbook, TTSH
 Handbook of Palliative Care, Second Edition (Christina
Faull, Yvonne H. Carter, Lilian Daniels)
 www.uptodate.com .

34. Thank You