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.