Dying is a natural process and unfortunately, something that we all come across in our daily jobs, including whilst on call. Despite this, very little time is dedicated during our training towards managing the dying patient. Instead, all the focus is upon saving and resuscitating the patient. The question is though, what do we do when that’s not an option? This guide is designed to help you out when on call and asked to review a patient who is approaching the end of life.
“You only die once, so let’s get it right”
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Introduction to End Of Life for Adult Patients
In an ideal world, all palliative patients (largely those with a progressive incurable disease with a prognosis less than 12 months) should be highlighted in the notes. Even more so, the patient’s regular team need to highlight those who are approaching the end of life, where death is imminent. This communication is invaluable to nursing staff and the on-call teams, particularly when the on-call doctor is asked to assess or review the patient.
It’s important that as a junior, wherever there is doubt, ALWAYS involve senior colleagues to help you with these decisions.
When asked to assess a deteriorating patient with a palliative/end of life diagnosis, sometimes a more holistic approach is required – remember that requesting lots of investigations may not always be appropriate for these patients at this stage. Think – is this person approaching the terminal phase? Will these investigations alter the outcome significantly or just prolong suffering? This is very nicely summarised by The Gold Standards Framework which has developed a Prognostic Indicator Guide to help aid in recognising the dying patient. If in doubt, always ask a senior for help!
If the consensus is that the patient is dying and entering the terminal phase, there are a few things that need to be considered.
- Does the patient or family want access to spiritual care
- What is the preferred place of death? Is this possible?
- Side room & access for the family 24/7
- Does the cause of death need to be considered early to expedite death certification for religions that necessitate burial within 24 hours?
- Does the patient have an ICD that needs turning off before their heart stops
Symptom Control
As doctors, one of our main roles is the anticipation of potential symptoms, where it is good practice to prescribe appropriate drugs, even if they are not yet formally on an “end of life care pathway” (simply more paperwork which states this fact). These are known as anticipatory medications and fall into four broad categories:
- Pain
- Nausea & vomiting
- Agitation
- Secretions
These should be prescribed on the PRN side of the chart so that nurses can give medications if/when symptoms arise. Not everyone suffers from all the symptoms; some don’t suffer from any at all. As such, leave all on the PRN side and titrate doses as necessary.
There can be many routes of administration – whilst able to tolerate meds, leave PO as an option but also all medications at the end of life setting may need to be given subcutaneously (S/C).
Continuous Subcutaneous Infusions (CSCI) – Syringe Drivers.
When patients require 2-3 PRNs of a medication within 24 hours, it is good practice to switch this to a regular medication especially in the S/C setting. A patient can be commenced on a syringe driver (CSCI) as this avoids unnecessary injections and discomfort as a small needle remains in situ. Ask the palliative care nurses for help on whether this is appropriate and how to prescribe this. The added benefit is that there is a continuous infusion and therefore a better delivery of a drug, rather than many peaks and troughs. Remember – only add drugs into the driver if the patient is having symptoms. There’s no need to put all four types of anticipatories in every driver!
Additionally, these devices are useful when a patient:
- Has difficulty swallowing
- Is vomiting ++
- Is in bowel obstruction
- Is too drowsy to swallow tablets
Below is a list with the key drugs and side effects to be aware of (though note not an exhaustive list!). Use your local guidelines & advice from palliative nurses to give you advice about which ones to use & what doses to aim for.
Pain
Morphine sulphate or Oxycodone (note oxycodone is twice as strong but is useful in renal impairment)
- Calculate regular doses by totalling the amount they’re using over 24 hours
- Breakthrough PRN doses are one-sixth of their total dose
- Side effects: N&V, constipation, opioid toxicity (drowsy, seizures)
Nausea & Vomiting
- Cyclizine – well tolerated
- Metoclopramide – contraindicated in bowel obstruction
- Haloperidol – extrapyramidal effects, contraindicated in Parkinson’s disease/Lewy Body disease
- Levomepromazine – can be sedating
- Octreotide – useful in malignant bowel obstruction
Agitation
Midazolam is usually the drug of choice. Helpful for patients who are having regular seizures too.
Secretions
Hyoscine hydrobromide – can sedate, give blurred vision & a dry mouth. Hyoscine butylbromide may be used as it is cheaper and less sedating. Often secretions are noisy but don’t trouble the patient.If you’re struggling or have any questions, options include:
- Contact a senior for advice
- Local guidelines
- Contact specialist palliative care services (in most places there is always a palliative care consultant on-call)
- Read about the Gold Standards Framework
- Online resources such as https://book.pallcare.info which is excellent for dose converting!
Dr Sadie Seal (ST1 Emergency Medicine)
Reviewed by Dr Becky Hirst (Consultant in Palliative Care)
