Palliative care consultant Dr Andrew Murray outlines strategies for managing common symptoms – other than pain – in the dying patient
Many patients experience distressing symptoms other than pain at the end of life.1 Good management of symptoms in the terminal phase is one of the main concerns of patients and their families.
The palliative care approach to symptom management should be based on thorough assessment of current symptoms, and planning ahead for common problems.
But bear in mind that the evidence base supporting prescribing for end-of-life symptoms is not well developed, and many prescribing practices in the palliative setting are either empirical or extrapolated from other settings.1
If treatment is ineffective in relieving suffering, sedation may be needed and guidelines for making this decision have been developed.2,3 But injudicious use of sedation occurs – often when distressing but potentially reversible symptoms have not been addressed properly.
In my experience, this can happen even when a patient is being cared for by a specialist palliative care team – and some of the best anticipatory care of dying patients I've seen has been done by GPs looking after patients who are dying at home.
Key principles are:
• Base medication choices and dosing on careful assessment of the dying person's symptoms and problems.
• Try to ensure doses are proportionate to symptoms and regularly reassess response as often as is practical.
• Consider the route of administration to minimise the burden of medication and potential side-effects – medications at the end of life are usually given subcutaneously, generally the least invasive and most reliable route in the dying patient.
• Medication for persistent symptoms needs to be given regularly rather than prn.
• Prn orders should be written for intermittent symptoms, and to cover possible ‘breakthrough' events for persistent symptoms.
• Anticipatory prn prescribing for problems which may occur during the dying process is an important aspect of good end-of-life care.
• To ensure prompt and effective symptom control, make sure caregivers are able to give the necessary medications.
Anxiety
It is rare to find a patient with a terminal disease who is not anxious at times, for reasons including fear of dying alone and fear of symptoms becoming uncontrollable. When anxiety starts to have an impact on a patient's quality of life, it's time to intervene.
Much anxiety can be eased with clear communication and simple measures. Acknowledge the patient's anxiety and help them express their feelings, needs and fears about the end of life. Simple techniques like relaxation therapy or distraction can be helpful.
Just getting someone to read a favourite book can help enormously. Aromatherapy and art therapy can also help.
But techniques that focus specifically on muscle relaxation can exacerbate anxiety in patients whose illness has made them very vigilant of bodily sensations.
Pharmacological measures to try include the following:
• For acute anxiety, try lorazepam 1-2mg sl prn or diazepam 2-10mg prn.
• For chronic anxiety, try an SSRI such as sertraline 50mg od or regular diazepam – consider a ß-blocker such as propranolol up to 40mg, eight hourly, if somatic symptoms are a problem, but bear in mind the risk of hypotension if used with lorazepam, temazepam or levomepromazine.
• If the anxiety is so severe that patients are tormented and not able to make decisions, start an antipsychotic such as risperidone 2-4 mg OD (or up to 1mg in the elderly). If sedation is needed, use olanzepine 5-10mg OD or levomepromazine 25-50mg eight-hourly orally or subcutaneously.
Breathlessness
Around two-thirds of terminally ill patients are affected by breathlessness – usually because of more than one cause.
Make sure the patient is positioned properly – breathlessness can often be improved by sitting in a more straight, upright position. A breeze over the face from a fan or an open window can also help. Many patients benefit from breathing exercises, including breathing from the diaphragm and controlling the breathing rate. General reassurance might be all some patients need, but there are a number of other strategies you could try:
• Oral or subcutaneous opioids can reduce the sensation of being short of breath – try starting with 2.5mg oramorph every four hours and titrating up.
• 2-5mg diazepam once or twice daily can be useful, or use background control with up to 2mg lorazepam sublingually prn for control of symptoms in between.
• Some patients experience breathlessness because of thick secretions, and nebulised saline can be helpful.
• Oxygen doesn't work for everyone, but is often worth trying.
Bleeding
Haemorrhage is a common fear, although only one in 10 patients with previous bleeds will die from haemorrhage. But it is very often a frightening event for the patient, who may need IV sedation quickly. Even minor bleeds can be distressing and patients should be given the option of being admitted for treatment.
Practical tips include:
• Make sure the patient is kept warm after a bleed and advise carers to keep dark towels to hand so they appear less alarming when used to soak up blood.
• Bleeds caused by coagulation problems are relatively uncommon. Chemotherapy, heparin, liver disease and some drugs can deplete platelets and some will need platelet transfusions. Liver failure can lead to abnormal clotting and patients will need daily fresh frozen plasma. Malabsorption can cause vitamin K deficiency which will need supplementation.
• Sucralfate can control bleeding associated with gastric cancer and can be applied directly to any visible bleeding point. Oral tranexamic acid inhibits fibrin clot breakdown, but should be avoided in haematuria since it can lead to obstructive, hard clots. Topical tranexamic acid reduces bleeding from rectal cancer.
• Dressings with very low adherence like physiotulle or mepitel are useful on their own and also for applying topical treatments. These and moist dressings like alginates and hydrogels can be left for up to a week.
• If the patient is distressed, give midazolam 5-15mg titrated IV – or orally or IM if not possible.
Nausea and vomiting
Nausea and vomiting occur in up to 50% of patients with cancer, and are also common in end-stage heart failure. Both cause huge distress for patients and their families – living with persistent nausea causes real misery. There are five key principles of management:
1. Assessment
Try to identify the cause. Ask the patient to describe its onset, pattern, precipitating or relieving factors and whether there is constipation. Also, assess the context of the nausea or vomiting, content of vomitus and the patient's hydration status.
2. Review medication
Antibiotics, cytotoxic drugs, iron supplements, NSAIDs, tranexamic acid and SSRIs can cause nausea and antimuscarinic drugs like amitriptyline, hyoscine, lofepramine and opioids can cause gastric stasis.
3. Try non-drug measures
• Relaxation/anxiety management/distraction
• Avoidance of unpleasant smells and food odours
• Acupuncture.
4. Select an antiemetic
If a cause can be identified, then choose an appropriate antiemetic and administer regularly rather than prn via an appropriate route.
5. Review
Make sure you try an anti-emetic at maximum dose for an adequate time. Nausea and vomiting caused by more than one factor may well need more than one drug.
Cough
Persistent coughing can be debilitating and very frightening, especially if accompanied by breathlessness. Consider the following options:
• Check for any treatable, reversible causes (see box).
• Ask the patient to try sitting upright.
• Nebulised saline or steam/menthol/Friars balsam inhalations can help.
• A linctus can help a dry cough, but if not try a low-dose oral opioid such as pholcodine, oramorph or codeine linctus.
• If the patient is already on opioids, try titrating the dose (up by 25% initially).
• 2-10md diazepam tds can act as a cough suppressant but also relieves associated anxiety.
For patients with specific conditions:
• Steam inhalations, intranasal steroids or drops can help for post-nasal drip.
• Try sodium cromoglycate 10mg qds for patients with lung cancer.
• Inhaled steroids can help if there is evidence of laryngeal irritation.
• Bronchodilators with or without steroids can help bronchospasm.
• Lower respiratory tract infections can be treated with nebulised saline to thin secretions – with or without antibiotics.
• Consider referral for radiotherapy if you think cough is associated with a tumour.
Constipation
Constipation is a common and distressing problem, and is often treatment related. Anticipation is the key to effective management. Abdominal examination and hydration status are important in the constipated patient. Rectal examination can be useful as is, occasionally, an abdominal X-ray. A few more suggestions include:
• Anyone at risk – patients on opioids, for example – should be taking laxatives, but both fentanyl and methadone are said to be less likely to cause constipation.
• If the faeces are hard, encourage increased fluid intake and start a combination of a stimulant laxative plus a softener such as lactulose.
• Bisacodyl suppositories are very effective, but only if in direct contact with the rectum.
• Consider referring to the district nurse for a phosphate enema if the above are not effective.
• Manual evacuation may occasionally be needed but should never be attempted without sedation and analgesia. Consent is vital.
Rattle
End-stage wet respirations, disturbingly still referred to as ‘death rattle', may occur at the very end of life – and are hugely distressing to carers, if not patients themselves. They occur when secretions build up in the throat and airway and patients are no longer able to clear them. Practical suggestions include:
• Try changing the patient's position. Turning a patient to their side may be enough to clear the secretions.
• Limit the amount of liquid being introduced into the mouth by gently squeezing excess water from wet sponges before moistening the mouth.
• Antimuscarinics reduce respiratory secretions but – while bearing in mind the point above – carers must be warned to take care to avoid dry mouth. Try 400-600mg hyoscine subcutaneously every four hours or 200mg glycopyrronium subcutaneously or IM every four hours.
Dr Andrew Murray is a community palliative care consultant for the St Mary Hospice group in south Wales
Competing interests None declared
Reversible causes of cough• Drugs – such as ACE inhibitors
• Treatment-related – such as radiotherapy
• GORD
• Heart failure
• Candidiasis
• Infection
• Bronchospasm
• Secretions
Step 1:
Choose a narrow-spectrum drug such as haloperidol, cyclizine or metoclopramide
Step 2:
Try an alternative or add in a second narrow-spectrum drug (consider dexamethasone if the cause is brain tumour or chemotherapy)
Step 3:
Try levomepromazine or a 5-HT3 antagonist such as ondansetron
Step 4:
Try increasing the levomepromazine dose or using dexamethasone
