From the Guidelines
The best approach for managing symptoms and providing end-of-life care for Lars involves establishing a comprehensive home-based palliative care plan, as this has been shown to improve quality of life, reduce symptom burden, and increase the likelihood of dying at home 1.
Key Components of Care
To achieve this, a multidisciplinary team including a palliative care physician, nurse, social worker, and chaplain if desired should be assembled. The team should prioritize pain management using a tiered approach, starting with scheduled acetaminophen and progressing to opioids such as morphine or fentanyl patches as needed. For bone pain, targeted radiation therapy or bisphosphonates like zoledronic acid should be considered.
- Urinary symptoms may require catheterization or medications like tamsulosin.
- Fatigue should be addressed through energy conservation techniques and treating reversible causes like anemia.
- Psychological support is essential, with medications like sertraline for depression if needed.
Advance Care Planning
Advance care planning discussions should occur early, documenting preferences regarding resuscitation, hospitalization, and artificial nutrition. Regular assessment using validated tools like the Edmonton Symptom Assessment Scale helps track symptom burden.
Family Support
Family caregivers should receive education, respite options, and emotional support to prevent burnout during this challenging time. This approach balances symptom control with Lars' wish to remain at home, preserving dignity and quality of life while avoiding unnecessary hospitalizations, as supported by the most recent guidelines and evidence 1.
From the Research
Managing Symptoms and Providing End-of-Life Care
To manage symptoms and provide end-of-life care for an 83-year-old patient with advanced metastatic castration-resistant prostate cancer who wishes to receive care at home, several factors need to be considered:
- The patient's symptoms, such as pain, anxiety, and dyspnea, need to be assessed and managed effectively 2.
- The use of high-dose morphine at home may be required to relieve the patient's pain, and it has been shown to be safe and not affect the patient's life expectancy adversely 3.
- A multi-disciplinary approach to care is recommended, including the advice of a pharmacist or clinical pharmacologist, to ensure that the patient receives the best possible care 4.
Essential Drugs for End-of-Life Care
The following drugs have been identified as essential for end-of-life care:
- Morphine, for pain relief 3, 5.
- Midazolam, for anxiety and dyspnea 5.
- Haloperidol, for nausea and vomiting, and terminal restlessness 5.
- An antimuscarinic drug, for respiratory tract secretions 5.
Non-Pharmacological Caregiving Activities
Non-pharmacological caregiving activities, such as:
- Bodily care and contact with patients and family members.
- Communication, including information, advice, and nonverbal presence.
- Creating an aesthetic, safe, and pleasing environment.
- Rituals surrounding death and dying, including spiritual, existential, legal, and professional rituals, are also important for providing holistic care to the patient and their family 6.