Otolaryngology Training Short on End-of-Life Care Advice

Hypercalcemia in the setting of cancer, dyspnea, and being in bed greater than 50% of the time would suggest a prognosis of three months remaining.

A prognosis of six months or less can be predicted in patients with brain metastases treated with palliative radiation and metastatic solid tumors without effective treatments, as well as other signs and symptoms of [central nervous system] atrophies, Russell said.

Treating Pain at End of Life

Patients who enter palliative care have a number of major symptoms that can all be addressed to increase comfort. The first key area is pain, much of which can be treated with opioid therapy.

Once patients are no longer treated with just short-acting opioids, one can institute a regimen of long-acting opioids every 12 hours as well as short-acting opioids given every four hours as needed, Russell said.

For nociceptive pain resulting from bone metastases, opioids aren’t enough and the patient needs to be treated with radiation therapy. Neuropathic pain, generally caused by nerve compression or central nervous system metastases, can be treated with gabapentin given every eight hours. In addition, patients can be given medications at night to help them sleep.

Breathing, Mental Status, and Hydration

Terminal patients commonly suffer from dyspnea, which can be due to obstruction or other causes. Simple measures should first be instituted here, including nasal oxygen, as well as a bedside fan for air movement which helps with the symptoms, he said. Also, morphine at a dose of 1 to 5 mg IV as needed can be effective.

Anxiety in terminal patients can be treated with lorazepam. Other changes in mental status can be treated with haloperidol, giving increased doses as needed. Low doses of stimulants can be used to treat depression in terminal patients.

Another factor many doctors don’t consider is the use of hospital chaplains on their end-of-life care team.

As for patients who have intractable pain, agitation, and other uncontrollable and distressful symptoms, the treatment of last recourse can be palliative sedation, given through continuous infusion of sedatives out of recognition that this will induce unconsciousness from which the patient may never recover, he said. The primary beneficial effect to the dying patient needs to be considered carefully with this approach.

Another issue with palliative sedation is hydration in the patient. Reducing the use of diuretics can help with water loss, plus appropriate levels of fluids can be administered.

On the other hand, not all patients will be institutionalized at end of life since many will prefer to spend their last days at home. Finding ways to help patients be at home can help reduce some of their stresses.