Care of the Imminently Dying
To assist with caring for the imminently dying, please refer to the CDHB End of Life Care Plan.
A diagnosis of dying is very important because it influences medical decision making. If you are not sure if your patient is dying, please refer to the guidelines on the CDHB End of Life Care Plan. Common signs that a patient is approaching the terminal phase are:
- Decreased intake of food and fluids.
- Increased tiredness/sleeping.
- Changing patterns of breathing.
- Rattling or noisy breathing.
When a patient is diagnosed as dying, patient comfort takes priority and increased support for family is needed. This is sometimes referred to as 'comfort cares' and is outlined in more detail on the CDHB End of Life Care Plan.
- 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.
- Maintenance of comfort and dignity are paramount with quality of life being the goal of care.
- See also When Death is Near. This is a good resource for family/whanau.
When the patient reaches the terminal phase, their ability to swallow medication is lessened – subcutaneous administration of medication will therefore be necessary.
- The patient’s symptoms need to be continuously assessed by all staff and documented fully in patient’s notes.
- Listen to the relatives – they know the patient best.
- To help with management of this phase, a phone consultation with the Palliative Care Service may be valuable.
- Regular essential medications (such as slow release morphine or anti-emetics) should be converted to the subcutaneous route. They should either be charted regularly, or via a subcutaneous infusion. See the opioid conversion guide.
- Pre-emptive or anticipatory prescribing is essential. See Anticipatory prescribing for patients with a terminal illness. PRN medications should be charted for control of symptoms that may arise, e.g:
- Pain / dyspnoea – morphine is first line in the absence of significant renal impairment. Consider a reduced dose in those >80 years (see Morphine). Whilst morphine 2.5 mg q4h subcut prn is a common starting dose in opioid naïve patients, this needs to be adjusted to individual patient circumstances. If eGFR is <30 ml/min/m2 then fentanyl is the drug of choice but can be difficult to use due to the short half-life. Please contact the Palliative Care Service for advice.
- Nausea – metoclopramide and haloperidol can be given as a subcut bolus. Cyclizine can only be given as a subcut infusion (See First-line Antiemetics).
- Agitation/anxiety – both midazolam and clonazepam can be given subcutaneously. Clonazepam is very long acting and should be given no more than 6 hourly. Conversely midazolam is very short acting and can be given frequently. Whilst midazolam 2.5 mg q1h subcut prn is a common starting dose in benzodiazepine naïve patients, this needs to be adjusted to individual patient circumstances. See Anxiety, Distress and Agitation.
- Delirium – haloperidol is the drug of choice. See Delirium.
Retained Airway Secretions (Death Rattle)
- See also section on Retained Secretions.
- Relatives who witness this can find it quite alarming and careful reassurance is essential.
- Some alleviation of this symptom can be achieved by using anticholinergic medications.
See also sections on:
This is also referred to as ‘Terminal Restlessness’ and may require ‘Palliative Sedation’.
Symptoms may include:
- Impaired consciousness
- Distressed vocalising
- Muscle twitching
- Exclude fear, anxiety, pain, faecal 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 – this requires careful discussion with family/whanau where circumstances permit.
Note: If severe and distressing symptoms, a referral to the Palliative Care Team is strongly recommended.
If complete sedation is required, the following drugs, administered parenterally, can be considered:
- Midazolam via subcut infusion starting at 10-20 mg/24 hours plus 2-5 mg subcut hourly prn. Midazolam is short acting and therefore prn use alone is not appropriate for terminal sedation.
- Clonazepam 0.5 mg q6h prn subcut or 1-4 mg /24 hours subcut via infusion. Clonazepam is very long acting and can be given as a regular BD dose in place of a continuous infusion if necessary.
- Levomepromazine (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. (Note: Levomepromazine was previously known as Methotrimeprazine.)
- Phenobarbitone is required on rare occasions and prescription must be initiated by the Palliative Care Service.
Newer agents such as olanzapine and risperidone have been found to be useful particularly if extra-pyramidal side effects are encountered but these are only available orally.
Topic Code: 4145