Managing Symptoms in Dying Patients
For patients who are dying, comprehensive symptom management is essential, focusing on pain, dyspnea, and depression as the primary symptoms requiring regular assessment and effective treatment. 1
Key Symptoms to Address
Pain Management
- Use therapies with proven effectiveness:
- For cancer patients: NSAIDs, opioids, and bisphosphonates 1
- For opioid-naive patients: morphine 2.5-10 mg PO every 2 hours as needed or 1-3 mg IV every 2 hours as needed 1
- For patients already on chronic opioids: consider increasing dose by 25% 1
- When tapering is necessary, reduce gradually (10-25% of total daily dose) at intervals of 2-4 weeks to avoid withdrawal symptoms 2
Dyspnea Management
- First-line interventions:
- For excessive secretions:
- Scopolamine 0.4 mg subcutaneous every 4 hours as needed, or
- Scopolamine 1.5 mg patches, 1-3 patches every 3 days, or
- Atropine 1% ophthalmic solution 1-2 drops SL every 4 hours as needed, or
- Glycopyrrolate 0.2-0.4 mg IV or subcutaneous every 4 hours as needed 1
Depression Management
- For cancer patients, use:
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors
- Psychosocial interventions 1
- Consider mirtazapine 7.5-30 mg at bedtime, which may also help with appetite 1
Anorexia/Cachexia Management
- Assess meaning of symptoms to patient and family
- Consider appetite stimulants:
- Megestrol acetate 400-800 mg/day
- Olanzapine 5 mg/day
- Dexamethasone 2-8 mg/day
- Cannabinoids 1
- Provide education about natural history of disease, including that absence of hunger and thirst is normal in dying patients 1
Nausea and Vomiting Management
- Identify and treat underlying causes:
- Discontinue unnecessary medications
- Check medication blood levels when appropriate
- Treat severe constipation if present
- For gastroparesis: metoclopramide 5-10 mg PO QID before meals and at bedtime
- For CNS involvement: dexamethasone 4-8 mg BID-TID 1
End-of-Life Care Considerations
When Death is Imminent (Weeks to Days)
- Intensify palliative interventions
- Consider palliative sedation for intractable symptoms 1
- Midazolam is often the first-choice medication for palliative sedation due to its rapid onset and short half-life 1
- Do not reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when needed for adequate symptom management 1
- Discontinue routine monitoring of vital signs; focus only on comfort parameters 1
Family Support
- Include family in discussions about care plans when possible 1
- Screen caregivers for practical and emotional needs 1
- Provide education and emotional support to family members 1
- Consider respite care for family caregivers to prevent burnout 1
Special Considerations
Nutritional Support
- Recognize that nutritional support may not be metabolized in advanced cancer
- Understand that withholding or withdrawing nutrition is ethically permissible and may improve some symptoms
- Treat dry mouth with local measures (mouth care, small amounts of liquids) 1
- For patients with diabetes at end of life:
- Focus on preventing hypoglycemia
- Consider discontinuing blood glucose monitoring
- For type 2 diabetes, discontinuation of all medications may be reasonable as the patient approaches death 1
Dignity Preservation
- Physical symptoms, particularly breathlessness, pain, and fatigue, significantly impact patients' sense of dignity 3, 4
- Address psychological symptoms which show consistent associations with dignity dimensions 3
- Equip patients with means for self-care when possible to preserve dignity 4
By systematically addressing these symptoms with proven interventions, healthcare providers can significantly improve quality of life and ensure comfort for patients in their final days.