The Deteriorating Patient
- 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
- Anticonvulsants for seizure control can be replaced with clonazepam 0.5-1mg subcutaneously or sublingually bd, and the dose increased if seizures occur.