What are the primary recommendations for managing end of life signs and symptoms?

Management of End-of-Life Signs and Symptoms

For patients with serious illness at the end of life, clinicians should regularly assess for and aggressively treat pain, dyspnea, and depression using evidence-based interventions including opioids, oxygen therapy when appropriate, and antidepressants. 1

Core Symptom Management

Pain Management

• Use specific effective therapies for all patients with acute and chronic pain, including NSAIDs, opioids, and bisphosphonates for cancer-related pain 1
• For cancer patients, bisphosphonates are particularly effective for bone pain relief in breast cancer and myeloma 1
• Morphine is considered an essential medication for quality end-of-life care, with careful titration based on symptom severity 2
• For refractory pain, palliative sedation can be considered after consultation with pain management/palliative care specialists 1

Dyspnea Management

• Opioids should be used for patients with severe and unrelieved dyspnea in cancer and cardiopulmonary disease 1
• For opioid-naive patients with months to weeks of life expectancy, administer morphine 2.5-10 mg PO every 2 hours as needed or 1-3 mg IV every 2 hours as needed 3
• Consider increasing opioid dose by 25% for patients already on chronic opioids 3
• Oxygen therapy should be used for short-term relief of hypoxemia in conditions like advanced COPD 1, 3
• Benzodiazepines can be added for dyspnea associated with anxiety, starting with lorazepam 0.5-1 mg PO every 4 hours as needed 3
• For excessive secretions ("death rattle"), use scopolamine 0.4 mg subcutaneous every 4 hours or 1.5 mg patches (1-3 patches every 3 days) 3

Depression Management

• Treat depression with tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions, particularly in cancer patients 1
• Regular assessment and management of depression symptoms is essential in patients with serious chronic diseases 2

Other Common End-of-Life Symptoms

Delirium

• Prevent delirium with normalization of environment when possible 4
• For symptomatic management, low-dose haloperidol is often effective 4

Gastrointestinal Symptoms

• Proactively treat opioid-induced constipation; consider parenteral methylnaltrexone for intractable cases 4
• For tumor-related bowel obstruction, use corticosteroids and octreotide 4
• Target therapy for nausea and vomiting to the underlying cause 4

Anorexia/Cachexia, Fatigue, and Terminal Restlessness

• Address these common symptoms as part of comprehensive end-of-life care 5
• For terminal restlessness, ensure adequate pain control and consider appropriate sedation if refractory 2

Advance Care Planning

• Ensure advance care planning, including completion of advance directives, occurs for all patients with serious illness 1
• Address specific elements such as surrogate decision makers, resuscitation preferences, and emergency treatment 2
• Care plans should be reassessed when significant clinical changes occur 2
• Discuss care directives with the patient, family members, and healthcare providers 2

Family and Caregiver Support

• Screen adult caregivers routinely for practical and emotional needs 1
• Allow and encourage family members to be with the patient 2
• Provide supportive care to family members, including listening to concerns and attention to grief 2
• Offer regular information updates about the patient's condition 2

Special Considerations and Common Pitfalls

• Undertreatment of dyspnea due to concerns about respiratory depression from opioids is a common pitfall, but evidence supports their safety and efficacy when appropriately dosed 3
• For patients at risk of catastrophic events at home, prepare sedating medications in advance with a clear plan for emergency administration 2
• Overreliance on oxygen therapy in non-hypoxemic patients can be ineffective 3
• Failure to address psychological and emotional components of symptoms can amplify distress 3, 6
• Delaying palliative interventions until the very end of life can reduce quality of life 3
• Team discordance and lack of understanding about symptom management by patients and families can be barriers to effective care 6

Medication Safety Considerations

• Monitor for morphine overdose signs: respiratory depression, somnolence, skeletal muscle flaccidity, cold/clammy skin, constricted pupils 7
• For lorazepam, be aware of potential for CNS depression, especially when combined with other medications or alcohol 8
• At the end of life, opioid dose should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate symptom management 1