Symptom Control during the Last Week of Life on a Palliative Care Unit

Abstract

A recent report suggested that more than 50 % of terminal cancer patients have physical suffering that requires sedation in the last days of life. To evaluate this finding on our 14-bed palliative care unit, a retrospective analysis of 100 consecutive patients admitted for 6 days or more was carried out. Information was collected on major symptoms requiring treatment, symptom control at admission and during each of the last 7 days of life, medications used, and changes that may have contributed to sedation. Of the 100 patients, 99 had pain, 46 had dyspnea, 71 had nausea, and 39 experienced delirium. Visual Analogue Scores (VAS) were done twice a day in all patients; mean pain showed a change from 31±24 on Day 6 to 24±19 on day of death (DOD) (p<0.05); nausea from 19±18 on Day 6 to 13±9 on DOD (p<0.01); drowsiness from 51±28 on Day 6 to 85±45 on DOD (p<0.001); symptom distress score from 49±11 on Day 6 to 52±9 on DOD (p<0.01). On the day of admission (DOA), 69 % of VAS were done by the patient and 28 % by the nurse as compared to 8 % by the patient and 90 % by the nurse on DOD. Level of consciousness on DOA was alert (72 %), drowsy (28 %), unresponsive (0 %) and by DOD was alert (2 %), drowsy (41%), unresponsive (57%). Symptom control on DOA was evaluated as good (64%), fair (26 %), poor (10 %) and by DOD was good (84 %), fair (14 %), poor (2 %). Evaluation of patient records and medication changes revealed 6/99 patients with pain (6 %) and 10/39 patients with delirium (26 %) requiring increased treatment, probably resulting in sedation in the last days of life. Thus, only 16 of 100 patients (16 %) required treatment for pain and delirium that would have caused sedation in order to achieve symptom relief.

Intravenous morphine consumption in outpatients with cancer during their last week of life—an analysis based on patient-controlled analgesia data

“…The comparison of our results with published reports on opioid need is made even more difficult by the fact that, in the published papers, the investigated treatment period ranged from 24 h to several weeks [3,4,17]. There are only three retrospective studies analyzing opioid doses administered in the patients' last week of life [10,11,23]. In their retrospective study, Fainsinger et al [10] demonstrated a significant increase of the mean daily opioid dose from 493 to 659 mg parenteral morphine equivalent.…”

“…There are only three retrospective studies analyzing opioid doses administered in the patients' last week of life [10,11,23]. In their retrospective study, Fainsinger et al [10] demonstrated a significant increase of the mean daily opioid dose from 493 to 659 mg parenteral morphine equivalent. In 31% of their patients, individual opioid dose increased during the last week of life.…”

“…This is the only study working with median (not mean) opioid doses. From a statistical point of view, operating with the median is preferable, as opioid doses in the last phase of life seem to lack normal distribution [7,10].…”

When to treat dehydration in a terminally ill patient?

“…In a retrospective review by our group [27] we reported agitated delirium in 10% of patients as the most frequent problem requiring sedation in the last week of life. In a later study [30], we noted that the severity of agitated delirium requiring sedation in our palliative care unit had decreased to 3%.…”

Treatment of nausea and vomiting in advanced cancer

“…Thirty percent of patients with a terminal illness vomit, and 60% have nausea. These symptoms are demoralizing, demeaning and reduce patients' quality of life [1][2][3][4][5][6]. Nausea contributes to cachexia of advanced cancer, and vomiting exacerbates any pain experienced by patients with metastatic disease.…”