Good management of symptoms in the terminal phase is one of the main concerns of patients and their families. The physical comfort of dying patients requires thorough assessment, excellent nursing care and careful prescribing.

What is known

• Many patients experience uncontrolled and distressing symptoms at the end of life. [1]
• The palliative care approach to symptom management is based on thorough assessment of current symptoms, and planning ahead for common problems. There is supportive evidence from a systematic review which showed a small but consistent positive impact of palliative care services on symptoms, quality of life, and satisfaction at the end of life. [2] Studies included in this review were extremely heterogeneous, and so these findings should be interpreted with care.
• The evidence base supporting prescribing for end-of-life symptoms is not well developed, and many of the prescribing practices which have developed are either empirical or extrapolated from other settings. [1] 
• If treatment is ineffective in relieving suffering, sedation may be needed. Guidelines for making this decision have been developed, based on systematic reviews and expert consensus. The guidelines discuss criteria for assessing refractoriness of symptoms, practical approaches to managing sedation, additional issues such as decisions about giving fluids, and the ethical distinction between palliative sedation and euthanasia. [3]

What it means in practice 
The principles of prescribing at the end of life are:

• Medications and doses prescribed should be based on careful assessment of the dying person’s symptoms and problems.
• Doses should be proportionate to symptoms identified, and response to treatment should be regularly re-assessed.
• The burden of how medication is given and of potential side effects should be minimised. Palliative care medications at the end of life are usually given via the subcutaneous route, which is generally the least invasive and most reliable route in the dying patient.
• Persistent symptoms require regular rather than PRN (as needed) orders.
• PRN orders should be written for intermittent symptoms, and to cover possible 'breakthrough' events for persistent symptoms.
• Anticipatory PRN prescribing for problems which may occur during the dying process (eg delirium / agitation; respiratory secretions; pain) is an important aspect of good end-of-life care. This may include crisis orders to cover foreseeable problems in particular patients, such as bleeding, severe respiratory distress, or seizures.
• To ensure prompt and effective symptom control, it is important to plan ahead for access to medications for the common symptoms which occur in dying patients, and make sure that caregivers are able to give the necessary medications. The practicalities of how this is managed will vary according to the setting of care – ie, whether the person is dying at home, in an acute hospital, in a nursing home, or in a palliative care unit.

Common physical problems which need to be assessed and planned for include:

• Pain
• Delirium / agitation
• Dyspnoea
• Respiratory secretions
• Mouth care and skin care
• Continence 
• Nausea, vomiting

Finding out more
Guidelines

• The medical care of older person in residential aged care facilities 
  Royal Australian College of General Practitioners 4th edition 2006 RACGP   
• Liverpool Care Pathway 
  Marie Curie Palliative Care Institute
• Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards.
  de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. Journal of Palliative Medicine. 2007 Feb;10(1):67-85. 

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on 'Notes on Prescribing'
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased.

Overview article

• ABC of palliative care: The last 48 hours. 
  Adam, J. ABC of palliative care: The last 48 hours.BMJ 315(7122):1600-1598, 1997 Dec 13. 

Related CareSearch pages
Pain
Opioid analgesics
Delirium
Nausea 
Breathing problems
Palliative care emergencies
Providing palliative care in aged care facilities

References

1. Von Gunten CF. Interventions to manage symptoms at the end of life. Journal of Palliative Medicine. 2005;8(suppl 1):S88-94.
2. Higginson IJ, Finlay IG, Goodwin DM, Hood K, Edwards AG, Cook A, et al. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? Journal of Pain and Symptom Management. 2003 Feb;25(2):150-68. 
3. De Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. Journal of Palliative Medicine. 2007 Feb;10(1):67-85. 

This page was created on 19 June 2008 and is due for review in June 2010
Last updated 19 June 2008