From the Guidelines
Hospice patients at the end of life typically experience a range of symptoms, including pain, dyspnea, and depression, which can be managed with evidence-based interventions, such as nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates for pain, and morphine for dyspnea, as recommended by the American College of Physicians 1.
Common Symptoms and Experiences
Hospice patients often experience a gradual decline in physical function, with symptoms that vary based on their underlying condition. Common physical experiences include:
- Increased fatigue
- Reduced appetite and thirst
- Changes in breathing patterns, such as Cheyne-Stokes respiration
- Decreased consciousness
Pain Management
Pain management is a cornerstone of hospice care, with medications like morphine (starting at 2.5-5mg every 4 hours as needed), hydromorphone, or fentanyl patches used to ensure comfort, as supported by strong evidence from trials of patients with cancer 1.
Dyspnea Management
Dyspnea can be managed with morphine, which has been shown to be effective in advanced lung disease and terminal cancer, with a standardized mean difference of −0.31 [CI, −0.50 to −0.13] 1.
Emotional and Spiritual Support
Hospice teams focus on symptom management rather than curative treatment, providing support not only for physical symptoms but also addressing emotional, spiritual, and psychological needs of both the patient and family throughout this natural process, as emphasized by the American College of Physicians 1.
Caregiver Support
Caregivers should be routinely and periodically screened for practical and emotional needs while caring for a patient near the end of life, and individualized multicomponent interventions may be more beneficial than more limited caregiver interventions, as shown by the REACH project 1.
From the FDA Drug Label
It may be necessary to provide the patient with lower dosage strengths to accomplish a successful taper Reassess the patient frequently to manage pain and withdrawal symptoms, should they emerge. Common withdrawal symptoms include restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate
The symptoms and experiences a hospice patient undergoes at the end of life are not directly addressed in the provided drug label. The label discusses opioid tapering and management of withdrawal symptoms, but does not provide information on the symptoms and experiences of hospice patients at the end of life 2.
From the Research
Symptoms Experienced by Hospice Patients
- Physical symptoms such as pain and dyspnea are common in the dying process 3
- Delirium and agitation may occur, which can be caused by reversible etiologies that should be identified and treated when feasible 3
- Nausea and vomiting should be treated with medications targeting the etiology 3
- Constipation may be caused by low oral intake or opiate use, and preventive regimens should include a stimulant laxative with a stool softener 3
- Oropharyngeal secretions may lead to noisy breathing, sometimes referred to as a death rattle, which is common at the end of life 3
Role of Nurses in Providing Comfort
- Nurses play a very important role in end-of-life comfort, which is based on a predisposition for end-of-life care and focused attention 4
- The nurse's role is essential in providing comfort care, and they are recognized by all those involved in this process as someone essential to providing comfort care 4
- Nurses can provide comfort through active listening, empathy, congruence, and biographical narrative, as well as global care, attention to detail, family support, and opposition to therapeutic obstinacy 4
Palliative Care at the End of Life
- The goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients 5
- As death approaches, a patient's symptoms may require more aggressive palliation, and support provided to the dying patient's family should intensify 5
- Palliative care focuses primarily on bereavement and support of the family after the patient's death 5
Medication Management
- A variety of medications are used for symptom control in palliative care, such as morphine, midazolam, and haloperidol 6
- The pharmacokinetics of these drugs may be altered in terminally ill patients due to physiological changes that occur at the end stage of life 6
- Opiates are the medication of choice for the control of pain and dyspnea, and haloperidol and risperidone are effective options for delirium 3