What is the best approach for managing end of life care?

Best Approach for Managing End of Life Care

The best approach for managing end of life care requires regular assessment of pain, dyspnea, and depression, using therapies of proven effectiveness for symptom management, and ensuring advance care planning occurs for all patients with serious illness. 1

Core Components of End-of-Life Care

Symptom Assessment and Management

• Regular and periodic assessment of pain, dyspnea, and depression is essential for all patients with serious illness at the end of life 1

• Pain management should include:

  • For cancer patients: NSAIDs, opioids, and bisphosphonates 1
  • For bone pain in breast cancer and myeloma: Bisphosphonates are specifically effective 1
  • Starting with immediate-release opioids to determine dose needed, then creating a regimen with extended-release formulation for daily pain plus immediate-release for breakthrough pain 2

• Dyspnea management should include:

  • Opioids for patients with unrelieved dyspnea in cancer and cardiopulmonary disease 1
  • Oxygen therapy for short-term relief of hypoxemia 1
  • β-agonists for treating dyspnea in chronic obstructive pulmonary disease 1

• Depression management should include:

  • For cancer patients: Tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions 1
  • Regular assessment and management of depression symptoms in patients with serious chronic diseases 1

Palliative Sedation

• For refractory symptoms at the end of life, palliative sedation may be considered 1
• Medications for symptom palliation used before sedation should be continued unless ineffective or causing distressing side effects 1
• For respite sedation (transient use to relieve severe symptoms):
  • Administer the lowest effective dose of sedative agent that provides adequate comfort 1
  • Monitor routine physiological parameters 1

Essential Medications

• Four essential drugs for quality care of the dying include:
  • Morphine (opioid) for pain and dyspnea
  • Midazolam (benzodiazepine) for anxiety and terminal restlessness
  • Haloperidol (neuroleptic) for nausea, vomiting, and delirium
  • An antimuscarinic drug for respiratory tract secretions 3

Advance Care Planning

• Advance care planning, including completion of advance directives, should occur for all patients with serious illness 1
• Care planning must address specific elements:
  • Surrogate decision makers
  • Resuscitation and emergency treatment preferences
  • Specific issues related to the patient's clinical course 1
• Care plans should be reassessed when significant clinical changes occur 1
• Care directives should be discussed with the patient, family members, and healthcare providers 1

Family and Caregiver Support

• Family members and friends should be:

  • Allowed and encouraged to be with the patient 1
  • Reassured that other methods have been sufficiently tried and that sedation is unlikely to shorten the patient's life 1
  • Kept informed about the patient's well-being and what to expect 1

• The care team should provide:

  • Supportive care to family members including listening to concerns and attention to grief 1
  • Regular information updates about the patient's condition 1
  • Opportunity to meet after the patient's death to express grief and discuss any concerns 1

Special Considerations

Home Care

• For patients at home and at risk of catastrophic events:
  • Sedating medications should be prepared in advance with a clear plan for emergency administration 1
  • Consider inpatient care if family members feel unable to administer emergency medications 1

End-of-Life Decision Making

• End-of-life decisions should be discussed in a multidisciplinary approach, considering:
  • Patient's directives
  • Family feelings and representatives' desires 1
• Palliative care team should be involved as soon as possible for managing severely injured elderly patients at end-of-life status 1

Common Pitfalls and Caveats

• Avoid undertreating pain due to concerns about opioid side effects; instead, anticipate and manage side effects proactively 2
• Patients taking opioids often experience constipation, so prescribing a laxative (e.g., senna, sorbitol) is advised 2
• When changing opioids or converting from oral to parenteral administration, use a conversion table to estimate the new dosage 2
• Nearing the end of life, the subcutaneous route of administration is preferred (94% at day of death versus 89% oral at admission) 4
• Many drugs used in palliative care are unlicensed for specific applications, and guidelines are often based on expert opinion rather than high-level evidence 4