The Deteriorating Patient

Key points

  • Identify that a patient is deteriorating (eg, largely bedbound, more time asleep or resting, declining or fluctuating oral intake, declining or fluctuating conscious state)
    • Recognise when deterioration is most likely due to untreatable causes, such as disease progression, or when the possible treatments are not wanted, or are burdensome and inappropriate
    • Explain to the patient and family
    • If some active treatment is still requested, choose the least burdensome options, offered as a time-limited therapeutic trial eg, 'if this trial of X does not help them stay more awake and active during the day, we will stop it in a few days'.
  • Be aware that continuing chemotherapy is generally not safe or clinically effective in a deteriorating patient who has become bed-bound 
    • Communicate with the treating team about the patient’s performance state.
  • Review all medications in the deteriorating patient 
    • Think about polypharmacy: reduce or stop longterm medications (eg, for ischaemic heart disease, osteoporosis, prophylaxis for DVT etc) except those that affect the patient’s comfort
  • Think about route of administration: loss of the ability to swallow is an inevitable part of deterioration
  • Consider deactivation of implantable cardioverter-defibrillator (AICD) devices to prevent delivery of shocks to a dying patient. 
    Implantable Cardioverter-Defibrillators at End-of-Life
  • Sometimes it is not possible to replace important medications that are usually taken orally
    • Aperients: consider judicious use of suppositories or other PR management
    • Adjuvant analgesics: if there is evidence of residual pain it may need to be treated by an increase in opioids – monitor carefully to see if this is required
    • Antidepressants
    • Anticonvulsants for seizure control can be replaced with clonazepam 0.5-1mg subcutaneously or sublingually bd, and the dose increased if seizures occur.

Managing comorbidities at the end-of-life

Managing comorbidities in patients at the end of life.

Chronic conditions require careful management in patients who develop a life limiting illness. Doctors need to consider both the physical and psychological effects of treatment. This article suggests a strategy for reviewing the ongoing need for long-term medications in the context of prognosis.

Ref: Stephenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ. 2004 Oct 16;329(7471):909-12.

Palliative Care Network of Wisconsin Fast Facts - Additional resources related to care of the deteriorating patient

# 111 Cardiac Pacemakers at End-of-Life
This Fast Fact discusses management of cardiac pacemakers at life’s end.

# 112 Implantable Cardioverter-Defibrillators at End-of-Life
Near the end of life, decisions as to how best to use these devices can be the source of much anguish for patients, families and palliative care/hospice staff.

# 174 Dementia Medications in Palliative Care
This Fast Fact will suggest guidelines for continued use or discontinuation in the hospice / palliative care setting.

# 258 Diabetes Management at the End-of-Life
Treatment goals for patients near the end-of-life are to avoid symptomatic hypo- and hyperglycemia and minimize the burdens of diabetes treatment, but not to prevent those long-term complications.

From: Palliative Care Network of Wisconsin Fast Facts (US)

Last updated 16 February 2017