Management of Physical Symptoms in Patients with Advanced Cancer during the Last Weeks and Days of Life

Abstract

As patients with advanced cancer approach the end-of-life (EOL) (i.e., last weeks to days), they often suffer from devastating physical and psychological symptoms [1,2]. These may include, but are not limited to, intractable pain, agitated delirium, and severe dyspnea, which can lead to immense suffering in terminally ill patients with cancer. Many symptoms remain under-recognized and under-treated in the last months of life, and often increase in intensity as patients approach death [3][4][5].Symptom control in the last weeks of life requires certain considerations. First, symptom assessment is often complicated by delirium and/or drowsiness. Second, symptom expression may be modulated by many unique factors that have relevance in the last days of life. For example, existential distress may increase symptom expression. Third, treatment decision making is highly dependent on patient survival and their expressed wishes. For example, a patient with depression may benefit from starting methylphenidate rather than antidepressants if they have an expected survival of a few weeks only. Fourth, caregiver distress is closely associated with patient's level of distress [6]. Support for and close coordination with caregivers is paramount to optimizing patient care.Clinicians looking after patients with advanced cancer in the last weeks to days of life need to be skilled in the manage-ment of these complex issues. Availability of a specialized interdisciplinary palliative care team is crucial. The team may provide care in the mobile consultation team setting or in palliative care unit (PCU). PCUs are particularly important because they offer intensive symptom management and care planning by a team of highly skilled palliative care professionals. These units are different from inpatient hospice facilities which are community-based; patients with a prognosis more than 6 months can be admitted to a PCU in a hospital setting for the management of physical, psychosocial, and spiritual distress [7][8][9].In this narrative review, we aim to provide an update on in-patient management of several of the most distressing physical symptoms occurring commonly in the last weeks to days of life, including pain, delirium, dyspnea, bronchial hypersecretions (death rattle) and intractable seizures. Other aspects of EOL care, such as psychosocial and spiritual issues and prognostication are covered in other articles in this issue. It should be recognized that there is a paucity of research studies specifically examining issues in the last weeks and days of life, with one literature review reporting that only 13% of palliative care studies involved patients in the last month of life [10]. This is related to many unique challenges in this setting, such as frailty in dying patients, difficulty with symptom assessment, delirium, rapidly changing health status, limited funding, and few palliative care researchers. Thus, many of the current practice patterns