The symptoms that cause suffering in hospitalized patients who are near death can be addressed by a variety of palliative interventions that improve the patient’s remaining life and ease the stress on both the patient and family members. A new review article summarizes.
Palliative care services can reduce the distress caused by symptoms and improve the quality of life of patients near the end of life. However, the current scarcity of board-certified palliative care specialists — a workforce shortage that is projected to continue far into the future — means that the responsibility for ensuring excellent end-of-life care for dying patients will continue to fall primarily on generalists and on specialists in areas other than palliative care. Thus, familiarity with basic comfort measures is an essential skill for all clinicians who are caring for patients whose death is imminent.
• What is meant by “comfort care”?
Comfort care requires the meticulous palliation of troubling symptoms and offering of skilled psychosocial and spiritual support to the patient and the patient’s family. However, the term is often used in a misleading or imprecise manner — for example, when such care is automatically considered equivalent to a do-not-resuscitate order and, perhaps even without discussion with the patient, is extrapolated to mean the exclusion of a full range of palliative measures appropriate for a dying patient. Rather than simply writing orders for “comfort care” (or “intensive comfort measures,” the term that the authors prefer), the medical team should review the entire plan of care and enter explicit orders to promote comfort and prevent unnecessary interventions.
• What is the treatment of choice for dyspnea in patients approaching death?
Dyspnea can be a debilitating symptom and may lead to substantial anxiety in the patient about the possibility of suffocating. A search for the underlying cause, especially when the degree of dyspnea changes rapidly, may occasionally be appropriate. However, such investigations should not be allowed to delay the treatment of symptoms. Opioids, given either orally or intravenously, are the treatment of choice for dyspnea and have been studied thoroughly in patients with COPD and patients with cancer; they have been found to be effective in alleviating dyspnea and, when used carefully, not to have serious side effects, such as respiratory depression. Patients are regularly given supplemental oxygen for dyspnea, but systematic reviews have found no benefit for patients with cancer or heart failure who do not have hypoxemia; however, oxygen may provide some relief for patients with COPD who do not have hypoxemia.
Morning Report Questions
Q: In the dying patient, does the treatment of neuropathic pain differ from that for somatic or visceral pain?
A: Neuropathic pain should be distinguished from somatic or visceral pain, since opioids alone may not provide adequate analgesia for patients with neuropathic pain. For patients with only a few days to live, adjuvant analgesics used for neuropathic pain may not have time to take effect; however, glucocorticoids may be of benefit in treating acute neuropathic pain. The combination of morphine with gabapentin produces analgesia that is more effective than that provided by either agent alone. Other agents (such as transdermal lidocaine, antidepressants, and anticonvulsants) may be considered when longer survival is anticipated.
Q: How should clinicians manage the excessive oral and pharyngeal secretions that are typically observed in the final days of life?
A: The inability to clear oral and tracheobronchial secretions is typically observed in the final days of life and can lead to gurgling sounds in the throat, sometimes referred to as a “death rattle.” Although family members and staff are often distressed by these sounds, they are unlikely to be disturbing to the dying patient, since they typically occur when the patient is unresponsive and lacks an effective cough reflex. The production of “grunting” sounds by the vocal cords is also common in dying patients. Simply repositioning the head may reduce these sounds and reassure loved ones that the patient is not in distress. No convincing evidence beyond clinical reports supports the commonly recommended use of antimuscarinic agents (e.g., atropine and glycopyrrolate) in patients with noisy breathing due to terminal respiratory secretions. A trial of glycopyrrolate can be considered, but the authors do not recommend its routine use, especially given the risk of such side effects as xerostomia, delirium, and sedation. Rather, clinicians should reassure and counsel family members and staff about the unlikelihood that the patient is experiencing discomfort from excessive secretions and about the lack of benefit and potential harm of treatment.