Managing symptoms in the last days of life
Managing symptoms in the last days of life is generally a continuation of symptom management. However, new symptoms may develop (eg respiratory sections), and pre-existing symptoms may worsen (eg breathlessness may increase as cachexia worsens) or diminish (eg pain may reduce when the patient becomes bed-bound).
Common symptoms in the last days of life include:
- pain
- altered breathing patterns, including breathlessness causing distress and excessive respiratory tract secretions
- nausea or vomiting
- agitation and restlessness.
Other problems that can occur include seizures and myoclonus.
The recommendations for managing symptoms in the last days of life are drawn from expert consensus based on limited evidence because conducting clinical trials in patients in the last days of life is challenging.
For general principles of symptom management in palliative care, see Principles of symptom management in palliative care.
Symptoms in the last days of life are managed using nonpharmacological interventions and, if indicated, drug therapy. Principles of drug therapy for symptoms in the last days of life are outlined in Principles of drug therapy for symptoms in the last days of life.
Closely monitor patients and individualise treatment as needed; patient needs can change rapidly during this time.
Seek immediate specialist palliative care advice if a patient appears to be distressed and does not settle despite adequate doses of drug therapy, or if there are other difficulties with symptom management.
Prescribe drugs in advance for anticipated symptoms and problems; this can help avoid a crisis or urgent transfer to hospital—see Anticipatory prescribing.
Rationalise drug therapy:
- Continue current drugs needed for symptom management.
- Ensure route of administration is appropriate. Continue drugs administered transdermally; other drugs are usually administered subcutaneously or sublingually.
- Stop drugs that are not needed for symptom control or are burdensome or harmful to the patient [NB1].
Prescribe as-required drugs (for intermittent or breakthrough symptoms) and regular therapy for ongoing symptoms. Include the indication for each drug on the prescription and drug chart. Some drugs can be used for multiple indications (eg morphine for pain or breathlessness, haloperidol for agitation or nausea and vomiting).
When selecting a drug and its dose and frequency, consider factors influencing medication management, including:
- patient factors, such as symptom severity, age, body size, sex, comorbidities (including kidney and liver disease), drug history and allergies
- practicalities, such as place of care, cost and availability of drugs and equipment, safety of drugs in the home and availability of suitable personnel to administer drugs [NB2]
- injection volumes for intermittent subcutaneous injections [NB3]
- drug compatibilities for continuous subcutaneous infusions [NB3].
Monitor the patient’s response to each drug for effectiveness and adverse effects [NB4]; if necessary, adjust the dose and frequency. Doses should be adequate to keep the patient comfortable without causing adverse effects.
If the patient does not respond to a drug within the expected time frame, check if anything is interfering with delivery or absorption (eg infusion pump not working, subcutaneous line kinked, dry mouth affecting absorption of sublingual drugs). Also consider whether a higher dose or an alternative or additional drug is needed.
If the patient appears to be distressed and does not settle despite adequate drug therapy or there are other difficulties with symptom management, seek immediate specialist palliative care advice.
NB1: Stopping a drug may cause significant distress. Provide support to patients, families and carers. Occasionally, it may be necessary to continue a drug even if it is no longer indicated, to avoid distress associated with stopping.
NB2: Teaching carers who wish to assist with drug administration in the last days of life may enable the patient to be cared for and die at home, particularly if access to after-hours support is limited; see Assisting patients and carers with medication management in palliative care and Assisting patients and carers to manage subcutaneous administration in the community.
NB3: For advice on subcutaneous drug administration, including injection volumes and drug compatibilities, see Subcutaneous drug administration in palliative care.
NB4: For patients taking opioids, do not use sedation score, consciousness level or respiratory rate to monitor for opioid toxicity. These features are unreliable measures of opioid toxicity in the last days of life because of the normal physiological changes that occur as death approaches; see Recognising when death is approaching. If opioid toxicity is a concern, seek specialist palliative care advice.