Palliative Care: End-of-Life Symptoms

Abstract

Ensuring the comfort and dignity of patients during the last hours of life is the cornerstone of palliative care. Like any aspect of supportive care and survivorship, high-quality care of the dying requires multidisciplinary expertise in the three core clinical skills: diagnosis, therapy, and prognosis. Although most cancer deaths are predictable, diagnosing that the patient is actively dying is not always easy, especially in the hospital setting. Indicators that patients are on the terminal pathway include: the patient becomes totally bedbound (typically 4–7 days before death); the patient is only able to take sips of fluid (typically indicating the last 48 h); the patient is semicomatose or only having mouth care (typically the final 24 h). The common symptoms in actively dying cancer patients include pain, restlessness (due to pain, delirium, or existential distress), retained secretions, breathlessness, and nausea. In most patients, all these problems can be controlled with just four drugs, which can all be given subcutaneously (or intravenously): an opioid, a benzodiazepine, a major tranquilizer, and an antimuscarinic agent. Occasionally, cancer patients die of a sudden catastrophic event due to hemorrhage, seizure, or choking and will require rapid sedation with a fast-acting benzodiazepine. In addition to these pharmacological maneuvers, therapy at the end of life includes stopping unnecessary tests and treatments, and clarifying preferences for life-sustaining treatment. Clarifying these preferences requires addressing the psychosocial and spiritual needs of the patient and family and incorporating their cultural values and attitudes into the plan of care. Care does not end with the death of the patient: support is needed for those who are experiencing loss, grief, and bereavement (patient, family, and staff).