What are the best practices for managing symptoms in a patient at the End of Life (EoL)?

Best Practices for Managing Symptoms at the End of Life

Effective symptom management at the end of life should focus on pain control with opioids, treatment of dyspnea with opioids and oxygen when appropriate, management of anxiety/delirium with benzodiazepines and antipsychotics, and discontinuation of non-essential medications to prioritize comfort and quality of life.

Pain Management

First-line Approach

• Opioids are the cornerstone of pain management for moderate to severe pain at the end of life 1, 2
• For opioid-naïve patients able to swallow:
  • Start with morphine sulfate immediate-release 2.5-5 mg orally every 2-4 hours as needed 1
  • Or morphine sulfate modified-release 5 mg twice daily (maximum 30 mg daily) 1
• For patients already taking opioids:
  • Morphine sulfate immediate-release 5-10 mg every 2-4 hours as needed 1
  • Or one-twelfth of the 24-hour dose for pain, whichever is greater 1
• For patients unable to swallow:
  • Morphine sulfate 1-2 mg subcutaneously every 2-4 hours as needed 1
  • Consider subcutaneous infusion via syringe driver if needed frequently (starting with morphine sulfate 10 mg over 24 hours) 1

Important Considerations

• Always initiate a bowel regimen when starting opioids (stimulant laxatives like senna) 2
• For patients with eGFR <30 mL/minute, use oxycodone instead of morphine 1
• NSAIDs and bisphosphonates may be added for specific pain types (e.g., bone pain in cancer) 1
• Monitor for side effects and adjust dosage to balance pain control and adverse effects 3

Dyspnea Management

Pharmacological Interventions

• Opioids are first-line treatment for unrelieved dyspnea 1, 2

  • Use the same agents as for pain management but often at lower starting doses
  • For moderate to severe breathlessness that is distressing, consider morphine as outlined in pain management section 1

• Oxygen therapy:

  • Provide for patients with hypoxemia 1, 2
  • Not routinely needed if oxygen saturation is normal 1

• For anxiety-related dyspnea:

  • Add benzodiazepines (e.g., lorazepam 0.5mg BID) 2

Non-pharmacological Techniques

• Positioning: Sitting upright, leaning forward with arms bracing a chair 1
• Controlled breathing techniques: Pursed-lip breathing, breathing exercises 1
• Relaxation techniques: Dropping shoulders to reduce hunched posture 1
• Airflow: Use of fans to move air across the face 2

Anxiety, Delirium, and Agitation Management

Assessment and Initial Approach

• First address reversible causes:
  • Explore patient's concerns and anxieties
  • Ensure effective communication and orientation
  • Ensure adequate lighting 1

Pharmacological Management

• For anxiety:

  • Benzodiazepines: Lorazepam 0.5mg BID 2

• For delirium/agitation:

  • First-line: Antipsychotics (haloperidol, chlorpromazine) 2
  • For terminal agitation: Midazolam when rapid effect is needed 2

• For refractory symptoms requiring palliative sedation:

  • Reserved for severe symptoms that are unresponsive to other treatments 1
  • Requires multidisciplinary team review and appropriate consent/assent 1
  • Does not hasten death when appropriately administered 1

Depression Management

• For patients with cancer, use tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions 1
• Consider psychosocial support alongside pharmacological management 1

Medication Discontinuation

• Discontinue medications that no longer provide benefit or may cause burden 2

• Consider stopping:

  • Diabetes medications (e.g., insulin, oral hypoglycemics)
  • Preventive medications (e.g., statins, antihypertensives)
  • Vitamins and supplements
  • Acid suppressants unless active GI symptoms are present 2

• When discontinuing opioids (if necessary):

  • Never abruptly discontinue in physically dependent patients 3
  • Taper gradually (no greater than 10-25% of total daily dose) 3
  • Monitor for withdrawal symptoms and adjust taper accordingly 3

Communication and Family Support

• Ensure advance care planning occurs for all patients with serious illness 1
• Discuss goals of care early and reassess when significant clinical changes occur 1
• Encourage family presence and provide guidance on comfort measures 2
• Reassure family that medications for symptom relief are unlikely to shorten life 2
• Provide regular updates about the patient's condition and expected changes 2

Common Pitfalls to Avoid

1. Inadequate symptom control: Underdosing pain or anxiety medications due to concerns about respiratory depression 2
2. Inappropriate medication continuation: Continuing chronic disease medications that no longer benefit the patient 2
3. Delayed response to symptoms: Not having PRN medications readily available 2
4. Overtreatment: Continuing interventions that cause more burden than benefit 2
5. Using antipyretics solely to reduce body temperature rather than for symptom relief 1
6. Failing to screen regularly for pain, dyspnea, and depression in patients with serious illness 1

By following these evidence-based approaches to symptom management at the end of life, healthcare providers can significantly improve patient comfort, dignity, and quality of life during this critical period.