With palliative care, curative options are discontinued except those that relieves symptoms (such as palliative chemotherapy) – palliative care focuses on relief of symptoms.
- According to the World Health Organization pain ladder, patients in severe pain (intensity of 7 to 10 on a 0- to 10- scale) should receive opioids, such as morphine and hydromorphone, plus continued adjuvant drugs.
- For effective start an opioid infusion, administer a bolus dose of approximately twice the normal bolus, until comfort or respiratory control is achieved. For instance, if the continuous infusion begins at 1mg/hour, the initial bolus should be 2mg, repeated until pain is relieved or respirations come under control.
- The starting dosage for a continuous infusion is 1mg/hour for morphine or 0.2mg/hour for hydromorphone, titrated to the patient’s comfort level.
- When used as a local anesthetic I.V. infusion for intractable pain, I.V. lidocaine is given as a bolus of 1 to 3 mg/kg over 20 to 30 minutes, with a continues infusion started once bolus administration is complete.
- For a patient receiving opioids when a ketamine infusion begins, reduce the opioid dosage by 25%. Ketamine infusion usually is controlled by a practitioner with special skills, such as a pain specialist or palliative care physician, and may be used as part of a terminal sedation protocol.
Delirium and Agitation
- A cognitive disturbance of acute onset, delirium occurs in several types – hypoactive, hyperactive, and a mix. Delirium affects cognition, attention, the sleep-wake cycle, mood, and speech.
- Haloperidol is the most effective drug for treating agitation. This drug is less sedating than lorazepam; also, lorazepam has proven ineffective in treating delirium
Opioids commonly are used to ease dyspnea, especially in cancer patients; current recommendations call for oral, I.V., or subQ opioid administration. if needed, a continuous infusion can begin once a bolus dose has provided sufficient dyspnea relief. Morphine is most commonly used; the starting dose is 1 to 2 mg/ hour, titrated upward as needed. Nebulized morphine hasn’t provided sufficient positive outcomes and isn’t recommended.
The principle of double effect is an ethical concept that supports taking certain actions that can cause both a desired effect and a harmful effect that one normally would strive to avoid. For instance, giving morphine to treat pain in a dying patient provides the best quality of life – but it may cause the adverse effect of hypoventilation or hypercarbia, which could lead to death.
For opioid-induced constipation, methylnaltrexone given subcutaneously 0.15 mg/kg can provide laxation in 4 hours. Sorbee brand candies containing sorbitol (which encourages laxation) can be used for milder constipation
To help dry up secretions, place a scopolamine patch behind the patient’s ear, as ordered. Suctioning at this time can cause discomfort and distress, leading to agitation and increased secretion production.
As death nears, the body begins to shut down and nutritional needs decrease dramatically. Ultimately, the body no longer requires nutrition, and hunger is suppressed.
Medications that can be used for palliative sedation include I.V. or subcutaneous midazolam and barbiturates, alone or in combination. The Mayo Clinic also endorses the use of propofol and ketamine.
Discussing the dying process can be helpful for family members. You may want to describe what occurs when someone dies. For example, explain how apnea begins, mentioning that the patient will take shallower breaths and apneic periods will grow more frequent as death nears. This can reassure the family and make it easier for them to stay at the patient’s bedside.