End-of-Life Care: Managing Common Symptoms

 

Physicians should be proficient at managing symptoms as patients progress through the dying process. When possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than to treat an acute symptom. As swallowing function diminishes, medications are typically administered sublingually, transdermally, or via rectal suppository. Opiates are the medication of choice for the control of pain and dyspnea, which are common symptoms in the dying process. Delirium and agitation may be caused by reversible etiologies, which should be identified and treated when feasible. When medications are required, haloperidol and risperidone are effective options for delirium. Nausea and vomiting should be treated with medications targeting the etiology. Constipation may be caused by low oral intake or opiate use. Preventive regimens to avoid constipation should include a stimulant laxative with a stool softener. Oropharyngeal secretions may lead to noisy breathing, sometimes referred to as a death rattle, which is common at the end of life. Providing anticipatory guidance helps families and caregivers normalize this symptom. Anticholinergic medications can modestly help reduce these secretions. Effective symptom control in end-of-life care can allow patients to progress through the dying process in a safe, dignified, and comfortable manner.

In its report “Dying in America,” the Institute of Medicine stresses that “all clinicians across disciplines and specialties who care for people with advanced serious illness should be competent in basic palliative care, including communication skills, interprofessional collaboration, and symptom management.”1 As clinicians assist patients and families through the course of disease, eventually, the care will focus on symptom management in the last weeks and days of life. Outside of the hospital, these care plans are directed by primary care physicians and subspecialists who have been managing patients' primary illness, often without the aid of a palliative medicine–trained physician. Therefore, it is imperative that clinicians understand how to help these patients achieve symptom relief. This review focuses on the outpatient management of common symptoms in persons at the end of life, whether in the home, assisted living facility, or nursing home environment.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Opiates should be used to treat dyspnea in end-of-life care.

B

35

Haloperidol and risperidone (Risperdal) are effective in treating delirium in end-of-life care.

C

17

Corticosteroids should be used in the management of bowel obstruction caused by malignancy. Octreotide (Sandostatin) has been shown to have limited benefit.

B

28, 29

Hyoscyamine (Levsin) or atropine ophthalmic drops can be used to treat excessive oropharyngeal secretions, although evidence supporting their use is limited.

C

33, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Opiates should be used to treat dyspnea in end-of-life care.

B

35

Haloperidol and risperidone (Risperdal) are effective in treating delirium in end-of-life care.

C

17

Corticosteroids should be used in the management of bowel obstruction caused by malignancy. Octreotide (Sandostatin) has been shown to have limited benefit.

B

28, 29

Hyoscyamine (Levsin) or atropine ophthalmic drops can be used to treat excessive oropharyngeal secretions, although evidence supporting their use is limited.

C

33, 34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

General Principles

Clinicians should follow certain guiding principles when prescribing medications for symptom management at the end of life. Medications should be used to treat the primary etiology of a symptom. For example, if a patient is anxious because of shortness of breath, treatment should focus on the dyspnea to alleviate the primary symptom and then the resulting anxiety.

Medications should generally start at lower dosages before titrating to the desired effect. The dosing should initially be as needed and then transitioned to

The Author

ROSS H. ALBERT, MD, PhD, is chief of the Division of Palliative Medicine at Hartford Hospital and medical director at Hartford HealthCare at Home Hospice, Hartford, Conn.

Address correspondence to Ross H. Albert, MD, PhD, Hartford Hospital, 80 Seymour St., PO Box 5037, Hartford, CT 06102 (e-mail: ross.albert@hhchealth.org). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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