This document summarizes palliative care and pain management at end of life. It defines palliative care as improving quality of life for patients with life-threatening illnesses through preventing and relieving suffering via early identification and treatment of pain and other physical, psychosocial and spiritual problems. The goals are establishing what patients want from their care, understanding their perspectives to guide therapy, and prioritizing comfort unless otherwise stated. Key aspects of end of life care discussed are adequate pain management, rationalizing medications, and communicating with patients and families.

1. Palliative care
and pain
management at
end of life
Brooke Sachs 2017

2. Definition
– Palliative care is an approach that improves the quality of life of patients and
their families facing the problem associated with life-threatening illness,
through the prevention and relief of suffering by means of early identification
and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual - World Health Organization
– This encompasses end-of-life care, but is also focused on the transition from
”active management” to quality-of-life care

3. Important tips and notes
– Early referral often makes life easier for patients and their families
– Talking to patients and their families about goals of care will help direct services
– Commencing on a palliative pathway does not necessarily mean taking away all
active treatment
– It is not “giving up” on patients
– Acute palliation is often more stressful and traumatic for all involved

4. Goals of care
– With any patient, it is important to establish what they want from therapy
– For example, some patients will want to get back to work as quickly as possible,
while others will want to try as many experimental drugs as possible
– Some patients have “bucket lists” while others are very content
– Understanding your patient’s perspective will help guide therapy
– It is important not to forget a patient’s right to autonomy

5. End of life care
– The priority is comfort (unless the patient has stated otherwise)
– Supplementary nutrition or hydration is not indicated – subcutaneous fluids are
occasionally used for severe thirst symptoms
– Mouth comfort cares can be completed by nursing staff or family
– Adequate analgesia is essential – this can be through a syringe driver
– Rationalise medications – only give medications that will relieve uncomfortable
symptoms
– Beware of impaired renal or liver function
– Communicate with the patient and their family

6. Restlessness
– Consider causes – pain/discomfort, urinary retention, emotional distress, build
up of toxic metabolites, withdrawal
– Manage by removing sources of agitation (loud noises), providing familiar
staff/family space, music therapy, only sedate if the patient is a danger to
themselves or others
– Pharmacological management includes haloperidol, clonazepam, midazolam

7. Secretions
– Due to the loss of the swallowing reflex
– Not normally disturbing to the patient
– Suctioning often increases patient discomfort
– Only use medication if the symptoms are very disturbing as they can increase
patient discomfort by drying out all surfaces (including eye mucosa etc)
– If necessary, use hyoscine hydrobromide of glycopurronium
– The ”death rattle” often means death will occur within 24h

8. Pain
– Physical discomfort does not have to be tolerated and can be treated
– Titrate analgesia to breakthrough requirements
– Consider non-pharmacological methods of pain relieve such as gentle motion,
massage etc
– If minimal pain requirements, consider ketorolac or ketamine for comfort

9. Resources
– Australian Palliative Care Curriculum modules http://www.pcc4u.org/
– Tasmanian Guidelines for Palliative Care
http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0016/47050/Care_Manage
ment_Guidelines_-_Terminal_Care_-_20160622.pdf
– WHO guide to palliative care
http://www.who.int/hiv/pub/imai/genericpalliativecare082004.pdf