Common Symptoms at Common Symptoms at End of LifeEnd of Life

Stephanie Reynolds, MSN, NP, Stephanie Reynolds, MSN, NP, ACHPNACHPN

Palliative Care, Jacobi Medical Palliative Care, Jacobi Medical CenterCenter

AssessAssess

Patient looks uncomfortable:Patient looks uncomfortable:Pain?Pain?Anxiety? Anxiety? Dyspnea?Dyspnea?

Make sure that you rule out:Make sure that you rule out:Discomfort because of hygiene needs, Discomfort because of hygiene needs,

need for repositioningneed for repositioningConstipation, urinary retentionConstipation, urinary retentionThirst, dry mouthThirst, dry mouth

Preventing Pain Preventing Pain

If the patient has a reason to have If the patient has a reason to have pain, they are likely in pain.pain, they are likely in pain.

Avoid repeated subcut injections if Avoid repeated subcut injections if possible – can be painful possible – can be painful

IV medication is best if pt is unable to IV medication is best if pt is unable to swallowswallowMay need to consider continuous drip to May need to consider continuous drip to

provide steady level of pain medication provide steady level of pain medication in bloodstreamin bloodstream

Preventing AnxietyPreventing Anxiety

Why is this patient agitated? Why is this patient agitated? May be pain, dyspnea, constipation, May be pain, dyspnea, constipation,

hunger…hunger…Avoid restraints Avoid restraints Order standing or prn medication for Order standing or prn medication for

anxietyanxietyAvoid Ativan IM, if possible; give either IV Avoid Ativan IM, if possible; give either IV

or SL or SL Chaplain?Chaplain?

Preventing DyspneaPreventing Dyspnea

Opioids very effective for dyspnea, Opioids very effective for dyspnea, but given at much lower doses than but given at much lower doses than for painfor paini.e. morphine liquid 2-5 mg PO or via i.e. morphine liquid 2-5 mg PO or via

GT/NGT q 6 hrs standingGT/NGT q 6 hrs standingAnxiolytics are also helpfulAnxiolytics are also helpfulConsider a fan at bedside (we have Consider a fan at bedside (we have

some!)some!)

Other SymptomsOther Symptoms

““Death rattle” / excess secretionsDeath rattle” / excess secretions Levsin 0.125 mg SL q 6 hrs around the clockLevsin 0.125 mg SL q 6 hrs around the clock Glycopyrrolate 0.1-0.2 mg IV q 8 hrs around the Glycopyrrolate 0.1-0.2 mg IV q 8 hrs around the

clockclock Diminished blinkingDiminished blinking

Natural tears eye drops, 2 drops to both eyes q 6 Natural tears eye drops, 2 drops to both eyes q 6 hrs and prnhrs and prn

Dry mouthDry mouth Artificial saliva, 5 mL q 6 hrs – apply to oral swab Artificial saliva, 5 mL q 6 hrs – apply to oral swab

for mouth carefor mouth care Ice chipsIce chips