From the Guidelines
End-of-life care for patients with brain hemorrhage should prioritize a palliative approach, focusing on comfort measures and symptom management to maximize quality of life and minimize suffering. The primary recommendations for end-of-life care in patients with brain hemorrhage include:
- Adequate pain control with medications such as morphine (2.5-5mg IV every 1-2 hours as needed) or hydromorphone (0.5-1mg IV every 1-2 hours as needed) 1
- Management of respiratory distress with morphine and benzodiazepines like lorazepam (0.5-2mg IV every 4-6 hours)
- Treatment of terminal agitation with haloperidol (0.5-2mg IV/SC every 4-6 hours) or midazolam (2.5-5mg IV/SC initially, then 1-2mg hourly as needed)
- Discontinuation of non-essential medications, artificial nutrition, and hydration is appropriate, while maintaining oral care and positioning for comfort 1
- Family support is crucial, including clear communication about the patient's condition, prognosis, and goals of care 1
These interventions are recommended because they address the common symptoms experienced during the dying process from brain hemorrhage, including increased intracranial pressure, which can cause pain, agitation, and respiratory changes. The goal is to maximize comfort and dignity while minimizing suffering, recognizing that brain hemorrhage patients often deteriorate rapidly, making timely implementation of these measures essential. According to the Canadian Stroke Best Practice Recommendations, a palliative approach should be used when there has been a catastrophic stroke or a stroke in the setting of significant pre-existing comorbidity, to optimize care for these patients, their families, and caregivers 1.
From the Research
Primary Recommendations for End of Life Care in Brain Hemorrhage
- The primary recommendations for end of life care in a patient with a brain hemorrhage include symptom management and palliative care 2, 3.
- Palliative care is now recognized as an essential component of comprehensive care in serious illness that interferes with quality of life, and its utilization in nontraumatic intracerebral hemorrhage has been increasing over the last decade 2.
- The care of patients nearing the end of life in the neurointensive care unit requires consideration of neuroanatomic localization, barriers to symptom assessment and management, unique aspects of the dying process, and end-of-life management needs 3.
Symptom Management
- Symptoms of discomfort in end-of-life care are mainly managed by drug therapy, with morphine, midazolam, and haloperidol being the most frequently used drugs 4.
- The doses of these drugs at the day of death are statistically significantly higher than at admission, and the subcutaneous route of administration is used in most patients at the day of death 4.
- A three-step practical algorithm for managing terminal hemorrhage in patients with advanced cancer who are no longer amenable to active interventional/invasive procedures includes preparing for the event, managing the event, and aftercare 5.
Palliative Care
- Palliative care teams should be integrated into emergency medical structures, and cooperation between palliative and emergency medical care is essential to optimize the quality of care in emergencies involving palliative care patients 6.
- The development of outpatient palliative care and the provision of emergency plans and emergency medical boxes can also help to optimize care 6.
- Independent predictors of palliative care use in patients with intracerebral hemorrhage include older age, female sex, Caucasian race, Medicare insurance, and higher Charlson comorbidity score 2.