Caring for patients right through to the end-of-life can be one of the most satisfying aspects of medicine. The support from their GP at this time is enormously valued by patients and their carers. As well as recognising and managing the terminal phase, GPs need to be aware of:
Recognising the terminal phase
There is a recognisable pattern of changes associated with the onset of the terminal phase in many patients, which usually means that the patient is actively dying. These symptoms have been described in EPERC as the syndrome of imminent death.
The duration of the terminal phase is hard to predict. It can range from short hours to many days. Family should be advised of this.
In patients with severe dementia and similar end-stage chronic conditions affecting the conscious state, it may be quite difficult to identify the onset of the terminal phase.
Managing a dying patient
The following general principles of end-of-life care can be applied in most situations. Where more complex problems are encountered, specialist help is available from your palliative care service.
The focus of care for a dying patient is exclusively on comfort. Above all, this requires good nursing care, and good assessment and management of symptoms.
Review all medications to minimise the burden of treatment on an actively dying patient:
- Consider which medications contribute to the patient's comfort and cease all others
- Consider route of administration – the subcutaneous route is preferred in palliative care of patients in the terminal phase who are not able to swallow.
- Anticipate symptoms which may arise in the last days and hours - the main concerns are likely to be pain, delirium/agitation, dyspnoea and terminal secretions. Consider how the carers will access medications and ensure that they have an adequate supply – especially for out of hours, weekends and public holidays.
Medications or prescriptions may be left for patients at their home or in the resdiential aged care facility, so that if problems arise, orders can be acted on quickly by either the family or nurses.
For medications which are difficult to access, or which require larger quantities than are provided by the usual PBS prescription, you may be able to obtain an Authority prescription. Your local palliative care service may be able to advise and help you if needed.
Just in case
Talk with the family about the implications of calling an ambulance. To prevent inappropriate attempts at resuscitation if an ambulance is called, a letter held by the family from the GP or other health professional can confirm the dying person’s palliative plan of management and resuscitation status.
Consider alerting your palliative care service of the possible need for an inpatient palliative care bed. If admission is needed, this may avoid the need to go through an emergency department.
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This page was created on 26 May 2009 and is due for review in May 2011.