What are the primary recommendations for managing signs and symptoms in dying patients?

Management of Signs and Symptoms in Dying Patients

Regular assessment and aggressive management of pain, dyspnea, and depression are the cornerstone recommendations for managing symptoms in dying patients, with opioids being the primary intervention for both pain and dyspnea management. 1

Primary Symptom Assessment and Management

Pain Management

• First-line therapies:
  • For cancer patients: NSAIDs, opioids, and bisphosphonates (for bone pain in breast cancer and myeloma) 1
  • Opioids can be titrated aggressively for moderate/severe acute/chronic pain 1
  • Palliative sedation should be considered for refractory pain after consultation with pain management/palliative care specialists 1

Dyspnea Management

• First-line interventions:
  • Opioids for patients with severe and unrelieved dyspnea 1
  • Oxygen therapy only for patients with hypoxemia 1, 2
  • Benzodiazepines when dyspnea is associated with anxiety 1, 2
  • Non-invasive ventilation (NIV) can be used as a palliative intervention to reduce symptoms of dyspnea but should not prolong the dying process 1
  • Hand-held fans may provide symptomatic relief 3

Depression Management

• Effective therapies for cancer patients:
  • Tricyclic antidepressants
  • Selective serotonin reuptake inhibitors
  • Psychosocial interventions 1

Special Considerations for End-of-Life Care

For Patients with Weeks to Days to Live

1. Anticancer therapy should be withheld 1
2. Focus should shift to intensive palliative care and symptom management 1
3. Important considerations:
   • Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for dyspnea and pain management 1
   • When discontinuing ventilation:
     • Provide adequate opioid therapy for dyspnea prophylaxis
     • Administer benzodiazepines for anxiety prophylaxis
     • Accept any unavoidable life-shortening side effects 1
     • Inform family members about possible physical reactions 1

For Patients with Advanced Non-Oncological Diseases

• NIV may be a treatment option when intubation with prolonged intensive care is not indicated or desired 1
• Ensure NIV does not cause more side effects or unnecessarily prolong the dying process 1

Advance Care Planning

• Should occur for all patients with serious illness 1
• Should address:
  • Surrogate decision makers
  • Resuscitation preferences
  • Emergency treatment plans 1
• Should be reassessed when significant clinical change occurs 1

Common Pitfalls to Avoid

1. Undertreating symptoms due to fear of side effects:

   • Do not reduce opioid doses solely for decreased vital signs when needed for symptom control 1
   • Any unavoidable life-shortening side effects should be accepted when providing adequate symptom relief 1

2. Prolonging the dying process:

   • Avoid continuing anticancer therapy in patients with weeks to days to live 1
   • Ensure NIV does not unnecessarily prolong the dying process 1

3. Poor communication:

   • Communication should be transparent, empathic, and authentic with both the healthcare team and patients/families 1
   • Avoid describing palliative/hospice care as "giving up" - reframe as "fighting" for better quality of life 1

4. Inadequate family support:

   • Family members should be informed about possible physical reactions when discontinuing interventions 1
   • Physicians should personally conduct and accompany the implementation of ventilation discontinuation 1

5. Delayed palliative care consultation:

   • Early involvement of palliative medicine specialists facilitates optimal symptom management and transitions of care 3
   • For prolonged ventilation, specialized palliative care teams should be consulted early 1

By following these evidence-based recommendations and avoiding common pitfalls, clinicians can effectively manage the distressing symptoms experienced by dying patients and improve their quality of life in their final days.