This document outlines the management of symptoms for patients in the last hours of life. It discusses signs of active dying like terminal delirium, death rattle, decreased urine output, and myoclonus. It provides guidance on interventions for specific symptoms like antipsychotics for delirium and medications for death rattle. The document also discusses the differences between respite sedation using a morphine drip and terminal sedation with a midazolam drip for refractory symptoms. Throughout, it emphasizes the goal of ensuring patient comfort in the last hours and days of life.

1. Symptom management
for the last hours
Patama Gomutbutra MD.

2. Outline
• Signs of active dying and how to deal with them
• Terminal delirium
• Death rattle
• Respiration with mandibular movement
• Decrease urine output
• Myoclonus and seizure
• Respite sedation VS Palliative sedation

3. Part I : Dealing with dying

4. Naturally,
Most of dying have ‘smooth’ pathway

5. Terminal delirium
Decrease appetites
Dysphagia of liquid
Death rattle
Respiration with mandibular movement
Decrease urine output
Seizure/myoclonus
Loss brain stem reflex
Loss of spinal cord function
month
week
day
hour

6. 6 signs of impending death within 72 hrs
Sens/spec
41/78
50/89
64/81
26/94
14/98
24/98
17/95
22/97
22/97
11/99
Hui D et al The Oncologist. 2014;19(6):681-687.

7. Should we give fluid to end of life patient?

8. Parenteral hydration
Pro
• Symbol of basic care:
Bond of provider and patient
• May lessen confusion,myoclonus
(75% of brain weight = water)
• Prevent adverse effect from high
dose narcotic
Con.
• Interfere the acceptance of
terminal condition
• Unconscious patient don’t feel
thirst, less pain
• Less secretion in respiratory and
GI tract, urine, ascites, edema
• Ketone is natural anesthesia

9. • P : 129 advanced cancer prognosis about 1 week with Hx and sign of
dehydration
Exclude severe dehydration (eg. BP drop),CHF, active bleeding
• I : SC 1000 cc per day
• C : SC 100 cc per day (placebo group)
• O : 0- 40 scale of dehydration symptoms (fatigue,
myoclonus,sedation and hallucinations)
Survival

10. Change from baseline
Outcomes Hydrated group
( n = 44)
Placebo
( n = 49)
p
value
Dehydration symptom
day 4, day 7
- Fatigue
-Drowsiness
- Hallucination
- Myoclonus
-3.3
- 4.9
-2.8
-3.8
0.77
0.54
MIDS (severity of delirium)
day 4, day 7
1
2
3.5
2.5
0.06 *
0.44
BUN -2 2 0.02 *
Cr -0.1 -0.1 0.25
Sodium 1.9 0.7 0.36
Calcium - 0.1 2.7 0.33

11. Survival : the same

13. Apply to practice
• In the last week of life, body may need fluid as less as
100 cc/day
• Meanwhile, not more harm
with 1000 cc/day
• Justify for who has risk for
- delirium
- Hypercalcemia

14. Terminal delirium
• Hypoactive - usually no problem
• Hyperactive
• Inevitable : Hope-ICU trial not support Haloperidol prophylaxis
• Increasing severity (conversely with pain)
• Most common cause of terminal sedation
• Antipyschotic
• Haloperidol 0.5-1 mg SC/IV q 2-8 hrs (may rapid titration if symptom severe)
average daily dose = 2-3 mg
• Quetiapine (Seroquel)
• Lorazepam not effective

15. Death rattle
• Gurgling sound produced on inspiration and/or expiration
related to airway secretions
• Ineffective swallowing and cough reflex
• Thin secretion
• Reduce IV hydration
• Furosemide
• Hyoscine hydrobromide (Buscopan) 0.4 mg IV q 6-8 hrs
• Thick secretion
• Saline nebulizure alternate with bronchodilator
• Acetylcystein
• Position

16. Respiration with mandibular movement
• Jaw movement increases with breath
• Asynchronous respiration muscle movement
* not related to hypoxemia
• O2 mask with bag -> not helpful but no harm
relieve sense of helpless of team

17. Dysphagia of liquid and decrease urine output
• Anuria or gross hematuria
• Depressed cardiac contractility -> low renal flow ->renal shut down
• IV hydration may worsening pulmonary congestion
• Consider off Foley's catheter if no concern about..
• End of life urinary incontinence
• Cholinergic induce urinary retention

18. Myoclonus and seizure
• Myoclonus common adverse effect of opioid
• Seizure
• 30-50% of brain tumor patient in the last month of life
• 2 % status epilepticus
• Both are response to BDZ
• If cannot swallow
• Lorazepam 1 mg sublingual then q 8 hrs
• Diazepam 10 to 20 mg per rectal thentwice a day

19. Part II : Sedation

20. Palliative sedation
• Respite sedation
-> temporary relieve severe distress
• Terminal sedation
-> last resort for refractory symptoms

21. Respite sedation regimen
• Morphine 10 mg in NSS 100 ml
IV drip start 1 mg/hr (10 ml/hr)
keep BP > 90/60
keep calm but awake
may add
• Lorazepam 0.5 -1 mg /day

22. Terminal sedation at home (Italian protocol)
• Midazolam continuous IV or SC
start 20-30 mg /day titrate up to 60 mg/day
• Concurrent use with other symptomatic med (ie. Opioid, Haloperidol)
• 24 end stage cancer, last 3 days of life, death at home
Marcadente et al,J Pain Symptom Manage 2014;47:860-66

23. Blurring between respite and terminal sedation
(my experience)
• During transition phase
Morphine 10 mg in NSS 100 ml IV drip 10-30 ml/hr
Midazolam 100 mg in NSS 100 ml IV drip 1 mg/hr
keep BP> 90/60, RR > 10/min
• During active dying – diminished pulse
Morphine 10 mg in NSS 100 ml IV drip 10 ml/hr
Midazolam 100 mg in NSS 100 ml IV drip 1-5mg/hr
keep comfort

24. Why Midazolam
• Ethical
• BDZ indication for sedation
• Opioid indication for relieve pain
( depressed conscious = impending depressed respiration)
• Short half life
• Able to use subcutaneous rout

25. Take home message
• Recognized signs of active dying -> shift goal to comfort care
• IV hydration and artificial nutrition in last hours had no benefit
• Prepared family member what expected in last hours
increase yield for peaceful death
• Respite sedation - Morphine drip
not need reserve only for active dying
• Terminal sedation – Midazolam drip
is the last resort for refractory dyspnea/delirium

26. Caveat : Last hours bias
• NR not mean “No response”
• Regular visit dying patient
• May be reversible cause
• Make the family ‘living’