Waikato DHB Palliative Care Guidelines

15. Care of the imminently dying

A diagnosis of dying is very important because it influences medical decision making. When a patient is diagnosed as dying, patient comfort takes priority and increased support for family is needed.

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Drug regimes must be simplified.
Active intervention such as IV fluids, blood transfusions, tests and investigations etc need to be discontinued after discussion with the patient and family.
Symptom control is the main priority.
Terminal restlessness is common and needs careful management – see below.
Maintenance of comfort and dignity are paramount with quality of life being the goal of care.

Symptom Management

When the patient reaches the terminal phase their ability to swallow medication is lessened – subcut administration of medication will therefore be necessary.

See relevant chapters for prescribing guidelines including chapter on subcutaneous administration. (Chapter 16)
The patient’s symptom’s need to be continuously assessed by all staff and documented fully in patient’s notes.
Listen to the relatives.
To help with management of this phase a phone consultation with the Palliative Care Service may be valuable.

15.1 Excessive airway secretions (death rattle)

See also Excessive Secretions

Relatives who witness this can find it quite alarming and careful reassurance is essential.

Some alleviation of this state can be achieved by using anticholinergic medications.

15.2 Terminal agitation

See also Agitation and Delirium.

This is also referred to as ‘terminal restlessness’ and may require ‘palliative sedation’.

Management

Agitation, impaired consciousness, distressed vocalising, muscle twitching, myoclonus, convulsions may all be signs of terminal agitation.

Exclude fear, anxiety, pain, impaction, urinary retention, drug, alcohol or nicotine withdrawal as possible causes.
Opioids can aggravate the problem or be the underlying cause – consider dose reduction.
Generally need to treat with sedation.

“Terminal agitation” may occasionally require complete sedation - the following drugs, administered parenterally, can be considered – refer to Agitation for prescribing guidelines.

Clonazepam.
Midazolam.
Methotrimeprazine (Nozinan™) – sedation is a side effect of this drug which may be helpful if benzodiazepines are contraindicated or proving ineffective or if it is already being utilised effectively for nausea and/or pain.

Newer agents such as olanzapine and risperidone have been found to be useful particularly if extrapyramidal side effects are encountered but these are only available orally.

Note: If severe and distressing symptoms a referral to the palliative care team is strongly recommended.

Information last reviewed: June 2009	Please foward any enquiries about this document to haggars@waikatodhb.govt.nz
Next review date: July 2010	For Palliative Care advice, please call 8691 or the specialist on-call.

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