How to manage fever in an end-of-life patient?

Managing Fever in End-of-Life Patients

For end-of-life patients with fever, antipyretic medications should be used only when fever causes discomfort, not routinely for the sole purpose of temperature reduction. 1

Assessment of Fever in End-of-Life Care

When an end-of-life patient develops fever, consider:

• Temperature measurement method: If central monitoring devices (pulmonary artery catheters, bladder catheters) are already in place, use these for accurate readings. Otherwise, oral or rectal temperatures are preferred over less reliable methods like axillary or temporal artery measurements 1
• Patient comfort level: Assess whether the fever is causing distress to the patient
• Hydration status: Check for signs of dehydration which may accompany fever

Management Approach

Comfort-Focused Treatment

1. Hydration

   • Advise regular fluid intake (no more than 2 liters per day) to avoid dehydration 1
   • Decisions regarding artificial hydration are independent of sedation decisions and should be based on whether they contribute to patient comfort 1

2. Pharmacological Management

   • Use paracetamol (acetaminophen) if the patient has fever and symptoms that would benefit from antipyretic treatment 1
   • Continue only while symptoms of fever are present 1
   • For patients who value comfort through temperature reduction, antipyretic medications are preferred over non-pharmacological cooling methods 1
   • In cases of intractable fever at end of life, diclofenac may be considered for continuous subcutaneous infusion 2

3. Non-Pharmacological Measures

   • Simple comfort measures such as light clothing, appropriate room temperature
   • Avoid aggressive cooling measures which may cause discomfort

Important Considerations

• The decision to treat fever should be based on patient comfort rather than the temperature value alone 1
• Routine use of antipyretics solely to reduce body temperature is not recommended 1
• For patients with severe symptoms related to fever, antipyretics can provide symptomatic relief even if they don't improve mortality outcomes 1

Special Situations

Imminently Dying Patients

• Routine monitoring of vital signs (pulse, blood pressure, temperature) is not necessary 1
• Focus only on parameters related to comfort 1
• A gradual deterioration of respiration is expected and should not alone constitute a reason to decrease sedation 1

Severe Symptom Burden

• For complex end-of-life cases with extreme symptom burden including intractable fever, multiple medications may be required 2
• In cases where fever is part of a constellation of distressing symptoms, consider palliative sedation with medications such as midazolam, particularly when death is imminent 1

Common Pitfalls to Avoid

1. Overtreatment of fever

   • Treating fever when it's not causing discomfort may unnecessarily burden the patient
   • Fever is an adaptive response and suppression may be potentially harmful in some cases 3

2. Undertreatment of distressing symptoms

   • Failing to provide adequate symptom relief when fever is causing discomfort
   • Remember that comfort is the primary goal in end-of-life care

3. Unnecessary diagnostic workup

   • Extensive testing for fever etiology may not be appropriate in end-of-life care unless it would meaningfully change management to improve comfort
   • Consider the goals of care before ordering diagnostic tests

By focusing on patient comfort rather than normalization of temperature, clinicians can ensure that end-of-life patients with fever receive appropriate, compassionate care that aligns with their goals and preferences.