Symptom management for the last hours

Patama Gomutbutra MD.

Outline

• Signs of active dying and how to deal with them• Terminal delirium• Death rattle • Respiration with mandibular movement• Decrease urine output• Myoclonus and seizure

• Respite sedation VS Palliative sedation

Part I : Dealing with dying

Naturally,Most of dying have ‘smooth’ pathway

Terminal delirium

Decrease appetites

Dysphagia of liquid Death rattle Respiration with mandibular movementDecrease urine outputSeizure/myoclonusLoss brain stem reflex

Loss of spinal cord function

month

week

day

hour

6 signs of impending death within 72 hrsSens/spec41/7850/8964/8126/9414/9824/9817/9522/9722/9711/99

Hui D et al The Oncologist. 2014;19(6):681-687.

Should we give fluid to end of life patient?

Parenteral hydration

Pro• Symbol of basic care:

Bond of provider and patient• May lessen confusion,myoclonus

(75% of brain weight = water)• Prevent adverse effect from high

dose narcotic

Con.• Interfere the acceptance of

terminal condition• Unconscious patient don’t feel

thirst, less pain• Less secretion in respiratory and

GI tract, urine, ascites, edema• Ketone is natural anesthesia

• P : 129 advanced cancer prognosis about 1 week with Hx and sign of dehydration

Exclude severe dehydration (eg. BP drop),CHF, active bleeding• I : SC 1000 cc per day• C : SC 100 cc per day (placebo group)• O : 0- 40 scale of dehydration symptoms (fatigue,

myoclonus,sedation and hallucinations) Survival

Change from baselineOutcomes Hydrated group

( n = 44)Placebo( n = 49)

p value

Dehydration symptom day 4, day 7

- Fatigue-Drowsiness- Hallucination- Myoclonus

-3.3- 4.9

-2.8 -3.8

0.770.54

MIDS (severity of delirium) day 4, day 7

12

3.52.5

0.06 *0.44

BUN -2 2 0.02 *Cr -0.1 -0.1 0.25Sodium 1.9 0.7 0.36Calcium - 0.1 2.7 0.33

Survival : the same

Apply to practice• In the last week of life, body may need fluid as less as

100 cc/day• Meanwhile, not more harm

with 1000 cc/day • Justify for who has risk for

- delirium- Hypercalcemia

Terminal delirium

• Hypoactive - usually no problem• Hyperactive

• Inevitable : Hope-ICU trial not support Haloperidol prophylaxis• Increasing severity (conversely with pain)• Most common cause of terminal sedation

• Antipyschotic• Haloperidol 0.5-1 mg SC/IV q 2-8 hrs (may rapid titration if symptom severe)

average daily dose = 2-3 mg• Quetiapine (Seroquel) • Lorazepam not effective

Death rattle

• Gurgling sound produced on inspiration and/or expirationrelated to airway secretions

• Ineffective swallowing and cough reflex• Thin secretion

• Reduce IV hydration• Furosemide • Hyoscine hydrobromide (Buscopan) 0.4 mg IV q 6-8 hrs

• Thick secretion • Saline nebulizure alternate with bronchodilator• Acetylcystein

• Position

Respiration with mandibular movement

• Jaw movement increases with breath• Asynchronous respiration muscle movement

* not related to hypoxemia• O2 mask with bag -> not helpful but no harm

relieve sense of helpless of team

Dysphagia of liquid and decrease urine output

• Anuria or gross hematuria• Depressed cardiac contractility -> low renal flow ->renal shut down• IV hydration may worsening pulmonary congestion• Consider off Foley's catheter if no concern about..

• End of life urinary incontinence • Cholinergic induce urinary retention

Myoclonus and seizure

• Myoclonus common adverse effect of opioid• Seizure

• 30-50% of brain tumor patient in the last month of life• 2 % status epilepticus

• Both are response to BDZ• If cannot swallow

• Lorazepam 1 mg sublingual then q 8 hrs• Diazepam 10 to 20 mg per rectal thentwice a day

Part II : Sedation

Palliative sedation

• Respite sedation-> temporary relieve severe distress

• Terminal sedation-> last resort for refractory symptoms

Respite sedation regimen

• Morphine 10 mg in NSS 100 mlIV drip start 1 mg/hr (10 ml/hr)

keep BP > 90/60 keep calm but awake

may add• Lorazepam 0.5 -1 mg /day

Terminal sedation at home (Italian protocol)• Midazolam continuous IV or SC

start 20-30 mg /day titrate up to 60 mg/day• Concurrent use with other symptomatic med (ie. Opioid, Haloperidol)• 24 end stage cancer, last 3 days of life, death at home

Marcadente et al,J Pain Symptom Manage 2014;47:860-66

Blurring between respite and terminal sedation(my experience)

• During transition phase Morphine 10 mg in NSS 100 ml IV drip 10-30 ml/hrMidazolam 100 mg in NSS 100 ml IV drip 1 mg/hrkeep BP> 90/60, RR > 10/min

• During active dying – diminished pulseMorphine 10 mg in NSS 100 ml IV drip 10 ml/hrMidazolam 100 mg in NSS 100 ml IV drip 1-5mg/hrkeep comfort

Why Midazolam

• Ethical • BDZ indication for sedation• Opioid indication for relieve pain

( depressed conscious = impending depressed respiration)

• Short half life• Able to use subcutaneous rout

Take home message

• Recognized signs of active dying -> shift goal to comfort care• IV hydration and artificial nutrition in last hours had no benefit• Prepared family member what expected in last hours

increase yield for peaceful death• Respite sedation - Morphine drip

not need reserve only for active dying• Terminal sedation – Midazolam drip

is the last resort for refractory dyspnea/delirium

Caveat : Last hours bias

• NR not mean “No response”• Regular visit dying patient

• May be reversible cause• Make the family ‘living’