Manage End-of-Life Symptoms Part 1 – Nursing Continue Education

Nurses frequently care for patients at the end of life. One of the challenges is managing end-of-life (EOL) symptoms such as dyspnea and pain. For patients nearing death, relieving distressing symptoms is perhaps the most valuable contribution you can make. Thus, the goal of patient care changes from cure to comfort.

End-of-life uncomfortable signs and symptoms: 

• In heart failure patient, dyspnea from fluid retention may cause agony (pain, anguish, or struggle, especially the struggle that precedes death)
• For Cancer patients, pain may predominate
• Other common end-of-life symptoms include agitation and delirium, anxiety, fatigue, weakness, constipation, nausea, and vomiting.
• how much time does the patient have left?
  • there’s no precise way to predict time of death, but certain signs and symptoms indicate the patient has reached a state where death could easily occur:
    • Death Rattle– noisy, rattling breathing caused by movement of pooled secretions in the throat.  (occurring in about 50% of terminal patients, this sign predicts death within 48 hours)
    • In patients with end-stage disease who have at least two of the following conditions are expected to have a mean of 2 days to live – bedridden, no longer able to swallow tablets, semicomatose, and able to take only sips of liquids.
  • Functional ability – key element in predicting how much time the patient may have left.

Palliative Care

• curative options are discontinued except those that relieve symptoms
• isn’t used until the patient reaches the brink of death
• it is not the same thing as terminal or hospice care

Pain Management – Top Priority

• Pain Assessment:
  • Self-report numeric pain intensity (NPI) rating scale with 0 being no pain and 10 the worst possible pain
    • a 2-point decrease in pain is deemed clinically significant
  • (unable to self-report) behavioral pain scale
• Pharmacologic: (World Health Organization ladder)
  • Step 1. Mild pain (NPI 1 to 3): acetaminophen; nonsteroidal anti-inflammatory drugs; adjuvant medications, such as tricyclic antidepressants and muscle relaxants
  • Step 2. Moderate pain (NPI 4 to 6): combination opioids, such as hydrocodone and acetaminophen or oxycodone and acetaminophen, plus continued adjuvant drugs.
  • Step 3. Severe pain (NPI 7 to 10): opioids, such as morphine and hydromorphone, plus continued adjuvant drugs.
    • Morphine (the gold standard for cancer pain)
    • hydromorphone (commonly used for pain relief at end-of-life)
    • extended-release forms of morphine, oxycodone, and hydromorphone can provide baseline for pain relief
    • short-acting opioids used for breakthrough pain
  • all patients receiving opioids regularly should be placed on laxative regimen to help prevent constipation
  • Patient-controlled analgesia (PCA) pump: opioids commonly used are morphine, hydromorphone, and fentanyl citrate
  • Epidural catheter: commonly used medications are preservative-free morphine and bupivacaine
    • The epidural catheter can remain in use for up to 30 days
    • it’s replace for another 30 days if needed
  • IV: lidocaine, ketamine

Resource retrieved from http://www.AmericanNuseToday.com:

D’Arcy, Y. (2012) Managing end-of-life symptoms: For patients nearing death, relieving distressing symptoms is perhaps the most valuable contribution you can make.