Last Days of Life

4/18/2014 Last Days of Life (PDQ®) - National Cancer Institute

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/page1/AllPages 1/30

Last Modified: 12/10/2013

Table of Contents

Overview

End-of-life Discussions

Palliative Care

Hospice

Symptom Management

Pain During the Final Hours of Life

Dyspnea

Fatigue

Cough

Death Rattle

Delirium

Fever

Hemorrhage

Ethical Issues

Nutritional Supplementation

Resuscitation

Ventilator Withdrawal

Palliative Sedation

Care During the Final Hours

Grief and Bereavement

Changes to This Summary (12/10/2013)

Questions or Comments About This Summary

About This PDQ Summary

Last Days of Life (PDQ®)

Health Professional Version



Purpose of This Summary

Reviewers and Updates

Levels of Evidence

Permission to Use This Summary

Disclaimer

Contact Us

Get More Information From NCI

Overview

Despite advances in the treatment of cancer, many people will die from their disease. This summary is

intended to address care during the last days to last hours of life, including common symptoms, ethical

dilemmas that may arise, and the role of the cancer care professional in caring for patients and their

families during this time.

In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are

discussed. The evidence and application to practice related to children may differ significantly from

information related to adults. When specific information about the care of children is available, it is

summarized under its own heading.

End-of-life Discussions

Although greatly feared by our death-denying society, the end of life can be a time of great personal

growth for patients and their families.[1] This growth depends on thoughtful discussions and careful

decision making about advance care planning, optimally beginning soon after diagnosis and continuing

throughout the course of the disease. Planning includes establishing the goals of care, clarifying

acceptable treatment options (including discussions regarding palliative care and hospice), and

determining where a patient wishes to spend the final days of life. When these discussions do not take

place and plans are not made, the final hours may be filled with suffering and distress.

In a large study of people with advanced cancer, patients who reported having end-of-life discussions

with their physicians (n = 188) had significantly lower health care costs than did patients who did not

have these discussions (n = 415). This was demonstrated by a reduction in resuscitation, ventilator use,

and intensive care stay. There was no difference either in survival time or in the likelihood of receiving

chemotherapy for patients who discussed end-of-life preferences with physicians (n = 75) and those who

did not (n = 70). Higher costs were associated with worse quality of life at death, as rated by the patient’s

caregiver (hospice nurse or family member).[2]

In a U.S.-based multisite, prospective, longitudinal study, advanced cancer patients and their caregivers

were followed to assess the association between end-of-life discussions and medical care, patient mental

health, and caregiver adjustment. The cohort consisted of 332 patients who died a median of 4 months

after enrollment, with 123 (37%) reporting end-of-life discussions with physicians at baseline. Results

demonstrated an association between discussions and less aggressive medical care near death and earlier

referrals to hospice. Aggressive care was associated with worse patient quality of life and caregiver



adjustment.[3] (Refer to the PDQ summary on Transitional Care Planning for more information on home

care needs.)

In a cross-sectional study of parents who lost a child to cancer, clear discussions between the primary

oncologist and the parents were more likely to be associated with planning for the location of death,

fewer hospital admissions, and parents feeling more prepared for the child's end of life.[4]

Palliative Care

Palliative care is an approach that can improve the quality of life for patients and their families facing

life-threatening illness through the prevention and relief of suffering by means of early identification and

impeccable assessment and treatment of pain and other physical, psychosocial, and spiritual problems.

[5] A randomized controlled study of early integrated palliative care with standard oncologic care versus

standard oncologic care alone in patients newly diagnosed with metastatic non-small cell lung cancer

revealed improved quality of life, fewer depressive symptoms, and longer median survival despite less

aggressive end-of-life care in the group receiving palliative care.[6]

Inpatient palliative care services are increasingly available in hospitals with more than 50 beds; between

2000 and 2011, the prevalence increased from 24% to 67%.[7] There is also experience with outpatient

palliative care clinics and home services. Regardless of the availability of palliative care services, all

oncologists and other professionals caring for people with cancer must be proficient in aggressive

symptom management and discussions of advance care planning. These activities are optimally

conducted with the palliative care team so that both patient and family hear a consistent message and do

not feel abandoned by the physician, with whom they have developed a strong bond.

Hospice

Hospice is a specialized form of interdisciplinary palliative care that alleviates physical, emotional,

social, and spiritual discomfort during the last phase of life. Hospice is a program of care provided by an

interdisciplinary team designed to keep a patient at home with family and friends. Pain management and

symptom management are paramount, along with bereavement and volunteer components. Hospice

provides palliative care, with which it is frequently confused; however, the focus of hospice is on

patients with life-limiting, progressive disease (usually with a prognosis of no more than 6 months if the

disease were to take its natural course).

Utilization of hospice care has increased in the United States, with more than 1.6 million individuals

seeking such care. People who had cancer made up approximately 38% of these admissions in 2011.[8]

However, a disturbing trend is reflected in the very short median length of stay in hospice of just 19.1

days. This trend suggests that advance care planning is not taking place early in the course of the disease,

that the ability of health care providers to prognosticate is poor, and that referrals are made too late; it

may also reflect denial on the part of professionals, patients, or their families regarding disease

progression. (Refer to the End-of-Life Decisions section of the PDQ summary on Transitional Care

Planning for more information.)

References

1. Byock I: Dying Well: The Prospect for Growth at the End of Life. New York, NY: Riverhead

Books, 1997.

http://www.cancer.gov/cancertopics/pdq/supportivecare/transitionalcare/HealthProfessional

http://www.cancer.gov/cancertopics/pdq/supportivecare/transitionalcare/HealthProfessional/Page8#Section_27




2. Zhang B, Wright AA, Huskamp HA, et al.: Health care costs in the last week of life: associations

with end-of-life conversations. Arch Intern Med 169 (5): 480-8, 2009. [PUBMED A bstract]

3. Wright AA, Zhang B, Ray A, et al.: Associations between end-of-life discussions, patient mental

health, medical care near death, and caregiver bereavement adjustment. JAMA 300 (14): 1665-

73, 2008. [PUBMED A bstract]

4. Dussel V, Kreicbergs U, Hilden JM, et al.: Looking beyond where children die: determinants and

effects of planning a child's location of death. J Pain Symptom Manage 37 (1): 33-43, 2009.

[PUBMED A bstract]

5. World Health Organization.: National Cancer Control Programmes: Policies and Managerial

Guidelines. 2nd ed. Geneva, Switzerland: World Health Organization, 2002.

6. Temel JS, Greer JA, Muzikansky A, et al.: Early palliative care for patients with metastatic non-

small-cell lung cancer. N Engl J Med 363 (8): 733-42, 2010. [PUBMED A bstract]

7. Center to Advance Palliative Care.: Growth of Palliative Care in U.S. Hospitals: 2013 Snapshot.

New York, NY: CAPC, 2013. Available online . Last accessed October 14, 2013.

8. NHPCO Facts and Figures: Hospice Care in America. 2012 Edition. Alexandria, Va: National

Hospice and Palliative Care Organization, 2012. Available online . Last accessed October 14,

2013.

Symptom Management

Symptoms commonly experienced at the end of life include pain, delirium, dyspnea, and rattle. In a

study of 200 patients with cancer, noisy breathing or rattle, pain, and urinary dysfunction were the

symptoms experienced most frequently during the last 48 hours of life.[1] In a large study of cancer

patients evaluated with the Edmonton Symptom Assessment System, average scores for pain, nausea,

anxiety, and depression remained relatively stable over the 6 months before death. However, shortness

of breath, drowsiness, well-being, lack of appetite, and tiredness increased in severity over time,

particularly in the month before death.[2] Other studies confirm that pain, fatigue, cough, delirium,

dyspnea, and other symptoms are common in the final days.[3-5];[6][Level of evidence: III];[7,8][Level

of evidence: II] Less common but equally troubling symptoms that may occur in the final hours include

fever and hemorrhage.

Pain During the Final Hours of Life

Many patients fear uncontrolled pain during the final hours of life, while others (including family

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=19273778&dopt=Abstract




http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf

http://www.nhpco.org/sites/default/files/public/Statistics_Research/2012_Facts_Figures.pdf

http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=663087&version=HealthProfessional&language=English




members and some health care professionals) express concern that opioid use may hasten death.

Experience suggests that most patients can obtain pain relief during the final hours of life and that very

high doses of opioids are rarely indicated.[9] Several studies refute the fear of hastened death associated

with opioid use. In several surveys of high-dose opioid use in hospice and palliative care settings, no

relationship between opioid dose and survival was found.[9-12]

Because consciousness may diminish during this time and swallowing becomes difficult, practitioners

should anticipate alternatives to the oral route. In a study of cancer patients at 4 weeks, 1 week, and 24

hours before death, the oral route of opioid administration was continued in 62%, 43%, and 20% of

patients, respectively. As patients approached death, the use of intermittent subcutaneous injections and

intravenous or subcutaneous infusions increased.[13] Both intravenous and subcutaneous routes are

effective in delivering opioids and other agents in the inpatient or home setting. For patients who do not

have a pre-existing access port or catheter, intermittent or continuous subcutaneous administration

provides a painless and effective route of delivery.[14] (Refer to the PDQ summary on Pain for a more

complete review of parenteral administration of opioids and opioid rotation.)

Myoclonic jerking can occur at any time during opioid therapy but is seen more frequently at the end of

life. The prevalence of opioid-induced myoclonus ranges greatly, from 2.7% to 87%.[15] Nocturnal

myoclonus is common and often precedes opioid-induced myoclonus.[16] The precise cause of opioid-

induced myoclonus is unknown; however, several mechanisms have been proposed.[17] High doses of

opioids may result in the accumulation of neuroexcitatory metabolites, the best characterized of which

are morphine-3-glucuronide and hydromorphone-3-glucouronide.[18];[19][Level of evidence: II] Serum

and cerebrospinal fluid levels as well as the ratios of these metabolites are elevated in patients who are

receiving morphine for cancer and nonmalignant pain and who have myoclonus.[20][Level of evidence:

II] This may be particularly true for patients with renal dysfunction, a common phenomenon in the final

hours of life.[20,21] However, clinical evidence of myoclonus does not consistently correlate with

serum levels of morphine-3-glucuronide.[22][Level of evidence: II] In rodents, hydromorphone-3-

glucuronide was more potent in its neuroexcitatory effects, including myoclonus, when compared with

morphine-3-glucuronide.[19] Furthermore, other opioids with no known metabolites also have been

shown to produce myoclonus.[23] Other opioids, including methadone,[24] meperidine,[25] and

transdermal fentanyl,[26][Level of evidence: II] have been implicated in the development of myoclonus.

[24]

Very high doses of an opioid may produce myoclonus. One group of investigators reported the

development of acute confusion, restlessness, myoclonus, hallucinations, and hyperalgesia due to an

inadvertent administration of high-dose intravenous fentanyl.[27] These symptoms were successfully

treated with several doses of 0.1 mg to 0.2 mg of intravenous naloxone followed by a continuous

infusion of intravenous naloxone (0.2 mg per hour).

Evaluation of the patient with myoclonus includes ruling out other known causes such as surgery to the

brain,[28] placement of an intrathecal catheter,[29] AIDS dementia,[30] hypoxia,[31] chlorambucil,[32]

metoclopramide,[33] and a rare paraneoplastic syndrome called opsoclonus-myoclonus.[34] The

etiology of the paraneoplastic syndrome can also be viral; symptoms include myoclonus, opsoclonus,

ataxia, and encephalopathic features.[35] The extent of the work-up to determine the cause of

myoclonus varies with the goals of care.

http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional







When opioids are implicated in the development of myoclonus, hydration and rotation to other opioids

are the primary treatments. There is great variability in individual response to opioids; thus, different

agents may be more likely to produce myoclonus or other adverse effects. Because cross-tolerance

between opioids is not complete, empirical evidence suggests that after an equianalgesic dose is

calculated, that dose should be reduced by approximately 25%, then titrated upward to meet the

patient’s analgesic needs.

In patients with rapidly impending death, the health care provider may choose to treat the myoclonus

rather than make changes in opioids during the final hours. Little research is available regarding the most

effective agents for reducing myoclonic jerking. Benzodiazepines, including clonazepam, diazepam, and

midazolam, have been recommended.[15,36,37] The mechanism of action of benzodiazepines is through

binding to gamma-aminobutyric acid type A receptors within the central nervous system (CNS), leading

to CNS depression. At higher doses, benzodiazepines may also limit repetitive neuronal firing, similar to

several anticonvulsant compounds such as carbamazepine.

The anticonvulsant gabapentin has been reported to be effective in relieving opioid-induced myoclonus,

[38] although other reports implicate gabapentin as a cause of myoclonus.[39,40][Level of evidence:

III] The antispasmodic baclofen has been used to treat myoclonus due to intraspinal opioid

administration.[41] Dantrolene has been used, but it produces significant muscle weakness and

hepatotoxicity.[15] In one small randomized study, hydration was found to reduce myoclonus.[42]

[Level of evidence: I] In cases of severe myoclonus, palliative sedation may be warranted.

Dyspnea

Dyspnea, described as shortness of breath or air hunger, is a common symptom in people with cancer

during the final days or weeks of life. The prevalence of dyspnea in adults diagnosed with cancer varies

from 21% to 90%, correlated with lung cancer and advanced disease.[43][Level of evidence: II] Dyspnea

may predict shortened survival. Patients with cancer presenting to an emergency center for treatment of

dyspnea had a median overall survival of 12 weeks.[44] Patients with lung cancer had a significantly

shorter survival (4 weeks) than did patients with breast cancer (22 weeks). In another study, patients

presenting to an emergency department with cancer-related dyspnea who were at greatest risk of

imminent death were those with an elevated pulse (100 or more beats per minute) and increased

respiratory rate (more than 28 breaths per minute), with a predicted mean survival of less than 2 weeks.

[45]

The etiology of dyspnea is usually advanced malignant disease, although other risk factors include

ascites, chronic obstructive pulmonary disease, deconditioning, and pneumonia. Dyspnea occurs when

more respiratory effort is necessary to overcome obstruction or restrictive disease (e.g., tumor or

pleural effusions), when more respiratory muscles are required to maintain adequate breathing (e.g.,

neuromuscular weakness or cachexia), or when there is an increase in ventilatory need (e.g.,

hypercapnia or metabolic acidosis).[46]

Opioids decrease the perception of air hunger, regardless of the underlying pathophysiology and without

causing respiratory depression.[47] This relief is dose related and, experimentally, is reversible by

naloxone, an opioid antagonist. Very low doses of opioid, such as morphine 2.5 mg orally, may provide

relief in opioid-naïve patients. Higher doses may be indicated in patients who have more intense dyspnea

or in patients who are using opioids for pain. As with pain control, gradual upward titration may be






needed to provide relief, particularly as symptoms progress.

The use of nebulized opioids for control of dyspnea remains controversial. Nebulized morphine has been

administered in the belief that this route would deliver the opioid directly to opioid receptors isolated

within the lung.[48] Initial uncontrolled clinical trials and case reports described efficacy using this

technique.[49] However, controlled trials have not confirmed these positive results, and as a result,

nebulized morphine is generally not indicated.[50] Initial trials of nebulized fentanyl, a lipophilic opioid,

suggest efficacy.[26][Level of evidence: II]

A randomized controlled trial of oxygen delivered versus room air, both delivered by nasal cannula and

worn at least 15 hours per day over a 7-day period, demonstrated no differences in breathlessness, with

no difference in side effects between the two groups. In light of the lack of benefit of oxygen therapy, the

investigators recommended that less burdensome therapies be selected.[51] Supplemental oxygen

appears to be useful only when hypoxemia is the underlying cause of dyspnea and is not effective in

relieving symptoms of dyspnea in people who do not have hypoxemia.[52,53] Alternate strategies

include positioning a cool fan toward the patient’s face and repositioning the patient into an upright

posture. Cognitive behavioral therapies such as relaxation, breathing control exercises, and

psychosocial support may be effective in relieving dyspnea, although patients in the final hours of life

may have limited capacity to participate in these techniques.[54][Level of evidence: I]

Complementary therapies such as acupuncture and acupressure have been demonstrated to be

beneficial for relieving dyspnea, although controlled trials are lacking.[55] Antibiotics may provide

relief from infectious sources of dyspnea; however, the use of these agents should be consistent with the

patient’s goals of care. If the patient experiences bronchospasm in conjunction with dyspnea,

glucocorticoids or bronchodilators can provide relief. Bronchodilators should be used with caution

because they can increase anxiety, leading to a worsened sense of dyspnea. In rare situations, dyspnea

may be refractory to all of the treatments described above. In such cases, palliative sedation may be

indicated, using benzodiazepines, barbiturates, or neuroleptics.

Fatigue

Fatigue at the end of life is multidimensional, and its underlying pathophysiology is poorly understood.

[56] Factors that may contribute to fatigue include physical changes, psychological dynamics, and

adverse effects associated with the treatment of the disease or associated symptoms. Stimulant

medications, along with energy conservation, may be warranted. (Refer to the PDQ summary on Fatigue

for more information.)

Cough

In some patients, chronic coughing at the end of life may contribute to suffering.[57] Chronic cough can

cause pain, interfere with sleep, aggravate dyspnea, and worsen fatigue. At the end of life, aggressive

therapies are not warranted and are more likely to cause increased burden or even harm. Symptom

control rather than treatment of the underlying source of the cough is warranted at this time of life.

Opioids are strong antitussive agents and are frequently used to suppress cough in this setting.

Corticosteroids may shrink swelling associated with lymphangitis. Antibiotics may be used to treat

infection and reduce secretions leading to cough. Patients with cancer may have comorbid nonmalignant

conditions that can lead to cough. For example, bronchodilators are useful in the management of



http://www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional



wheezing and cough associated with chronic obstructive pulmonary disease, and diuretics may be

effective in relieving cough due to cardiac failure. Additionally, a review of medications is warranted

because some drugs (e.g., ACE inhibitors) can cause cough.

Anecdotal evidence suggests a role for inhaled local anesthetics, which should be utilized judiciously and

sparingly; they taste unpleasant and suppress the gag reflex, and anaphylactic reactions to preservatives

in these solutions have been documented. In cases of increased sputum production, expectorants and

mucolytics have been employed, but the effects have not been well evaluated. Inhaled sodium

cromoglycate has shown promise as a safe method of controlling chronic coughing related to lung

cancer.[58]

Refer to the PDQ summary on Cardiopulmonary Syndromes for more information.

Death Rattle

Rattle, also referred to as death rattle, occurs when saliva and other fluids accumulate in the oropharynx

and upper airways in a patient who is too weak to clear the throat. Rattle does not appear to be painful

for the patient, but the association of this symptom with impending death often creates fear and anxiety

for those at the bedside. Rattle is an indicator of impending death, with an incidence of approximately

50% in people who are actively dying. There is some evidence that the incidence of rattle can be greatly

reduced by avoiding the tendency to overhydrate patients at the end of life.[59,60]

In one prospective study of 100 terminally ill cancer patients, rattle began at an average of 57 hours

before death.[61][Level of evidence: II] Other studies suggest the median time from onset of rattle to

death is much shorter at 16 hours.[62] Two types of rattle have been identified: real death rattle, or type

1, which is probably caused by salivary secretions; and pseudo death rattle, or type 2, which is probably

caused by deeper bronchial secretions due to infection, tumor, fluid retention, or aspiration.[60,63] In

one retrospective chart review, rattle was relieved in more than 90% of the patients with salivary

secretions, while patients with secretions of pulmonary origin were much less likely to respond to

treatment.[60]

The pharmacologic treatment of rattle includes antimuscarinic agents, which antagonize acetylcholine

(and are thus termed anticholinergic) to reduce secretions.[64] The most commonly used agents include

scopolamine, glycopyrrolate, atropine, and hyoscyamine.[59,64] Few data exist to support the use of

one agent or route over another. Because most patients are unable to swallow at this time, transdermal

or parenteral routes are employed most frequently. Scopolamine, also called l-hyoscine or hyoscine, is

available in oral, parenteral, transdermal, and ophthalmic formulations. Some clinicians begin treatment

by applying one or two scopolamine transdermal patches behind the ear. Noticeable reduction in

secretions usually occurs within 1 or 2 hours after application. If the patch is ineffective, a scopolamine

infusion is initiated, with a starting dose of 50 µg per hour intravenously or subcutaneously and titrated

upward to 200 µg or more per hour. Adverse effects include CNS depression, although paradoxical

excitation has been reported.

Glycopyrrolate (Robinul) is commercially available parenterally and in oral tablet form. Doses typically

range from 1 mg to 2 mg orally or 0.1 mg to 0.2 mg intravenously or subcutaneously every 4 hours, or

by continuous intravenous infusion at a rate of 0.4 mg to 1.2 mg per day. Glycopyrrolate is less likely to

penetrate the CNS, and fewer adverse effects are reported than with other antimuscarinic agents, though

http://www.cancer.gov/cancertopics/pdq/supportivecare/cardiopulmonary/HealthProfessional




this is probably of little consequence in the use of glycopyrrolate to relieve rattle at the end of life.

Other drugs that can assist with reducing secretions are atropine and hyoscyamine.[59,64] Doses for

these agents are included in the table on Common Symptoms at End of Life and Their Treatment. In

addition to these agents, diuretics such as furosemide can sometimes eliminate excess fluids that build

up in the upper airways. Reducing parenteral fluids can help reduce excess secretions. None of these

measures appear to be effective when the underlying cause of rattle is deep fluid accumulation, such as

occurs with pneumonia.[65][Level of evidence: II]

Common Symptoms at End of Life and Their Treatment

Enlarge

Sy m pt om Ma n a gem en t

My oclon u s Con sider et iolog y (u su a lly h ig h -dose opioidsa dm in ister ed ov er a pr olon g ed per iod).

Hy dr a te.

Rota te to a lter n a te opioid.

Use ben zodia zepin es; if pa t ien t ca n n ot sw a llow , u sem ida zola m or lor a zepa m .

Dy spn ea Use opioids (sm a ll, fr equ en t doses a s n eeded for opioid-n a ïv e pa t ien ts [e.g . , 2 .5 m g m or ph in e PO ev er y h ou rpr n ]; opioid-toler a n t pa t ien ts w ill r equ ir e dosea dju stm en t a n d u pw a r d t itr a t ion ).

Use ben zodia zepin es on ly if a n x iety is pr esen t .

Use g lu cocor t icoids or br on ch odila tor s forbr on ch ospa sm .

Use a n t ibiot ics if ca u se is in fect iou s a n d th is iscon sisten t w ith g oa ls of ca r e.

Use ox y g en on ly w h en h y pox ia is pr esen t .

Dir ect a cool fa n tow a r d th e fa ce.

Reposit ion (elev a te h ea d of bed; if pa t ien t h a sn on fu n ct ion in g lu n g , posit ion on side w ith th a t lu n gdow n ).

Use cog n it iv e-beh a v ior a l th er a pies su ch a s g u idedim a g er y .

Use in teg r a t iv e th er a py su ch a s a cu pu n ctu r e.

Fa t ig u e Use m eth y lph en ida te (Rita lin ) 2 .5 m g tw ice da ily (ina .m . a n d a t n oon ) to sta r t ; in cr ea se u p to 3 0 m g /da y ;a n x iety a n d r est lessn ess m a y occu r .

Use d-a m ph eta m in e (Dex edr in e) 2 .5 m g /da y to sta r t ;in cr ea se u p to 3 0 m g /da y ; a n x iety a n d r est lessn essm a y occu r .

Use m oda fin il (Pr ov ig il) 5 0–1 00 m g /da y to sta r t ;in cr ea se to 1 00–2 00 m g /da y .

Su g g est en er g y con ser v a t ion m eth ods.

Em ploy sleep h y g ien e m ea su r es.

(Refer to th e PDQ su m m a r y on Fa t ig u e for m or ein for m a tion .)

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/Page2#Section_81


http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/Table1

http://www.cancer.gov/cancertopics/pdq/supportivecare/fatigue/HealthProfessional



Cou g h Con sider et iolog y (in fect ion , br on ch ospa sm , effu sion s,ly m ph a n g it is, ca r dia c fa ilu r e) a n d tr ea t a ccor din g ly .

Use opioids (sm a ll, fr equ en t doses to sta r t for opioid-n a ïv e pa t ien ts; opioid-toler a n t pa t ien ts w ill r equ ir edose a dju stm en t a n d u pw a r d t itr a t ion ).

Use oth er a n t itu ssiv es su ch a s g u a ifen esin ordex tr om eth or ph a n .

Use g lu cocor t icoids su ch a s dex a m eth a son e to m a n a g ecou g h du e to br on ch it is, a sth m a , r a dia t ionpn eu m on it is, a n d ly m ph a n g it is.

Use br on ch odila tor s su ch a s a lbu ter ol 2 –3 in h a la t ion sev er y 4 –5 h ou r s for br on ch ospa sm lea din g to cou g h .

Use n on seda t in g a n t ih ista m in es w ith or w ith ou tdecon g esta n ts for sin u s disea se. (Su g g est n on seda t in ga g en ts if fa t ig u e or seda t ion is a pr oblem .)

Use diu r et ics to r eliev e cou g h du e to ca r dia c fa ilu r e.

(Refer to th e PDQ su m m a r y on Ca r diopu lm on a r ySy n dr om es for m or e in for m a tion .)

Ra tt le Use scopola m in e tr a n sder m a l pa tch , 1 .5 m g (sta r tw ith on e or tw o pa tch es; if in effect iv e, sw itch to 5 0µg /h ou r con tin u ou s IV or SQ in fu sion a n d dou ble th edose ev er y h ou r , u p to 2 00 µg /h ou r ).

Use g ly copy r r ola te, 1 –2 m g PO; or 0 .1 –0.2 m g IV orSQ ev er y 4 h ou r s; or 0 .4 –1 .2 m g /da y con tin u ou sin fu sion .

Use a tr opin e, 0 .4 m g SQ ev er y 1 5 m in u tes pr n .

Use h y oscy a m in e, 0 .1 2 5 –0.2 5 m g PO or SL ev er y 4h ou r s.

Ch a n g e posit ion or elev a te h ea d of bed.

Redu ce or discon tin u e en ter a l or pa r en ter a l flu ids.

A v oid su ct ion in g .

Delir iu m Stop u n n ecessa r y m edica t ion s.

Hy dr a te.

Use h a loper idol, 1 –4 m g PO, IV , or SQ ev er y 1 –6h ou r s pr n .

Use ola n za pin e, 2 .5 –2 0 m g PO a t bedt im e.

(Refer to th e PDQ su m m a r y on Delir iu m for m or ein for m a tion .)

Fev er Use a n t im icr obia ls if con sisten t w ith g oa ls of ca r e.

Use a n t ipy r et ics su ch a s a ceta m in oph en .

A pply cool cotton cloth s.

Giv e tepid spon g e ba th s.

Hem or r h a g e Use v ita m in K or blood pr odu cts for ch r on ic bleedin g ifcon sisten t w ith g oa ls of ca r e.

Use a m in oca pr oic a cid (PO or IV ).

In du ce r a pid seda t ion w ith IV m ida zola m w h enca ta str oph ic h em or r h a g e occu r s.

http://www.cancer.gov/cancertopics/pdq/supportivecare/cardiopulmonary/HealthProfessional

http://www.cancer.gov/cancertopics/pdq/supportivecare/delirium/HealthProfessional



PO = by m outh; prn = as needed; IV = intravenous; SQ = subcutaneous; SL = sublingual.

Use blu e or g r een tow els to m in im ize distr ess.

Nonpharmacologic interventions include repositioning the patient by elevating the head of the bed or

turning the patient to either side. Reducing or eliminating additional fluids and feedings alleviates

additional fluid accumulation in the body. Family members may request suctioning, but this can be

traumatic and cause bleeding or stimulate the gag reflex. If truly indicated, suctioning should not be

done beyond the oral cavity.

Delirium

Delirium is common during the final days of life.[5,66] There are two general presentations of delirium:

hyperactive and hypoactive. (Refer to the PDQ summary on Delirium for a complete review.) The

hyperactive form of delirium includes agitation, hallucinations, and restlessness.[67] In hypoactive

delirium, the patient is withdrawn and quiet; as a result, this form of delirium may be underdiagnosed.

[68][Level of evidence: II][66] Although the etiology of either form of delirium is poorly understood,

metabolic changes (e.g., hypercalcemia, hypoglycemia, opioid metabolites), dehydration, and drug

interactions are implicated.[68-70][Level of evidence: II] Other potential causes of delirium include

cancer within the CNS, a full bladder, fecal impaction, dyspnea, or withdrawal from alcohol or

benzodiazepines.

Care of the patient with delirium can include stopping unnecessary medications, reversing metabolic

abnormalities (if consistent with the goals of care), treating the symptoms of delirium, providing

parenteral hydration,[71] and providing a safe environment. Agents known to cause delirium include

corticosteroids, chemotherapeutic agents, biological response modifiers, opioids, antidepressants,

benzodiazepines, and anticholinergic agents. In a small, open-label, prospective trial of 20 cancer

patients who developed delirium while being treated with morphine, rotation to fentanyl reduced

delirium and improved pain control in 18 patients.[70][Level of evidence: II] To limit the potential for

drug interactions, medications that are no longer useful or that are inconsistent with the goals of care

should be stopped. For example, cholesterol-lowering agents are rarely beneficial at this time of life, but

many patients admitted to hospice remain on these medications.

Onset of effect and nonoral modes of delivery should be considered when an agent is being selected to

treat delirium at the end of life. Agents that can relieve delirium relatively quickly include haloperidol, 1

mg to 4 mg orally, intravenously, or subcutaneously.[72] The dose is usually repeated every 6 hours but

in severe cases can be administered every hour. Other agents that may be effective include olanzapine,

2.5 mg to 20 mg orally at night (available in an orally disintegrating tablet for patients who cannot

swallow).[73][Level of evidence: II] Although benzodiazepines (such as lorazepam) or atypical

antipsychotics typically exacerbate delirium, they may be useful in delirium related to alcohol

withdrawal and for hyperactive delirium that is not controlled by antipsychotics and other supportive

measures. Chlorpromazine can be used, but intravenous administration can lead to severe hypotension;

therefore, it should be used cautiously.[74] In intractable cases of delirium, palliative sedation may be

warranted. Safety measures include protecting patients from accidents or self-injury while they are

restless or agitated. The use of restraints is controversial; other strategies include having family

members or sitters at the bedside to prevent harm. Reorientation strategies are of little use during the

http://www.cancer.gov/cancertopics/pdq/supportivecare/delirium/HealthProfessional







final hours of life. Education and support for families witnessing a loved one’s delirium are warranted;

one survey of family members found high levels of distress caused by observing delirium.[75][Level of

evidence: II]

In dying patients, a poorly understood phenomenon that appears to be distinct from delirium is the

experience of auditory and/or visual hallucinations that include loved ones who have already died.

Although patients may sometimes find these hallucinations comforting, fear of being labeled confused

may prevent patients from sharing their experiences with health care professionals.[76] Family

members at the bedside may find these hallucinations disconcerting and will require support and

reassurance. Consultation with the patient’s or family’s minister, rabbi, priest, or imam; the hospital

chaplain; or other spiritual advisor is often beneficial.

Fever

Terminally ill patients experience a high incidence of fever and infections.[77,78] A number of

retrospective studies have shown that a large number of patients who are receiving hospice or palliative

care are treated with antibiotics for suspected or documented infections.[79-81];[82][Level of evidence:

II]

The benefits and burdens of the use of antimicrobials in this patient population are topics of much

discussion.[79,80,82,83] Three prospective studies have suggested that symptom control may be the

main objective in the decision to use antimicrobials to treat clinically suspected or documented

infections in patients who are receiving palliative or hospice care.[84-86][Level of evidence: II]

Difficulties in treating symptoms include predicting which patients will obtain symptom relief and which

patients will experience only the additional burdens of treatment. Determining the cause of fever (e.g.,

infection, tumor, or another cause) and deciding which symptoms from suspected infections might

respond to various antimicrobial interventions can be difficult clinical judgments, particularly in

patients who have multiple active medical problems and for whom the goal of treatment is symptom

control.

Hemorrhage

Hemorrhage is an uncommon (6%–10%) yet extremely disturbing symptom that can arise from cancer

or its treatment.[33,87,88] Patients at particular risk include those with head and neck cancers with

tumor infiltration into the carotid artery.[88] Radiation therapy to this region can result in thinning of

the walls of the vessels, increasing the risk of bleeding. Slow leakage of blood from eroded areas can

signal risk of hemorrhage; however, early signs are frequently not apparent, and bleeding can occur

without warning. Other cancers that can lead to sudden hemorrhage include gastric or esophageal

cancers that perforate, leading to a rapidly fatal upper gastrointestinal bleed.[33,87] Leukemias and

other hematologic disorders place patients at risk for hemorrhage. Disseminated intravascular

coagulopathy, idiopathic thrombocytopenia, or other platelet abnormalities can lead to sudden

hemorrhage.

When chronic bleeding occurs, management may include hemostatic dressings or agents, radiation

therapy, endoscopy, arterial embolization, or surgery may be warranted. Systemic interventions include

the use of vitamin K or blood products. However, the goals of care are comfort oriented when






catastrophic hemorrhage occurs at the end of life. Optimally, code status has already been discussed;

resuscitation is rarely effective. Supportive care is critical, for both the patient and family members at

the bedside. Although survival after hemorrhage is very limited (usually a few minutes), patients may be

initially aware of events around them. Fast-acting agents such as midazolam may sedate the patient

during this distressing event.[89]

The following steps should be taken when bleeding occurs:

Cover the area with dark-colored (e.g., blue or green) towels to limit visual exposure to the blood.

Speak calmly and reassure the patient that he or she is not alone (and, if loved ones are in

attendance, let the patient know they are there).

Clean the area rapidly because blood can produce a foul odor that may be distressing to loved ones.

Provide support to family members.

Oncology, palliative care, and other units that care for patients at risk for hemorrhage should have

supplies (towels, sedatives) and standing orders in place for rapid employment. Support is essential for

all members of the health care team, including novice clinicians or nonclinical staff who might be in

attendance, such as chaplains or social workers. Team members should be encouraged to verbalize their

emotions regarding the experience, and their questions should be answered.

References

1. Lichter I, Hunt E: The last 48 hours of life. J Palliat Care 6 (4): 7-15, 1990 Winter. [PUBMED

A bstract]

2. Seow H, Barbera L, Sutradhar R, et al.: Trajectory of performance status and symptom scores for

patients with cancer during the last six months of life. J Clin Oncol 29 (9): 1151-8, 2011. [PUBMED

A bstract]

3. Morita T, Tsunoda J, Inoue S, et al.: Contributing factors to physical symptoms in terminally-ill

cancer patients. J Pain Symptom Manage 18 (5): 338-46, 1999. [PUBMED A bstract]

4. Back IN, Jenkins K, Blower A, et al.: A study comparing hyoscine hydrobromide and

glycopyrrolate in the treatment of death rattle. Palliat Med 15 (4): 329-36, 2001. [PUBMED A bstract]

5. Hall P, Schroder C, Weaver L: The last 48 hours of life in long-term care: a focused chart audit. J

Am Geriatr Soc 50 (3): 501-6, 2002. [PUBMED A bstract]

6. Potter J, Hami F, Bryan T, et al.: Symptoms in 400 patients referred to palliative care services:

prevalence and patterns. Palliat Med 17 (4): 310-4, 2003. [PUBMED A bstract]









7. Georges JJ, Onwuteaka-Philipsen BD, van der Heide A, et al.: Symptoms, treatment and "dying

peacefully" in terminally ill cancer patients: a prospective study. Support Care Cancer 13 (3): 160-


8. Doorenbos AZ, Given CW, Given B, et al.: Symptom experience in the last year of life among

individuals with cancer. J Pain Symptom Manage 32 (5): 403-12, 2006. [PUBMED A bstract]

9. Thorns A, Sykes N: Opioid use in last week of life and implications for end-of-life decision-

making. Lancet 356 (9227): 398-9, 2000. [PUBMED A bstract]

10. Bercovitch M, Waller A, Adunsky A: High dose morphine use in the hospice setting. A database

survey of patient characteristics and effect on life expectancy. Cancer 86 (5): 871-7, 1999.

[PUBMED A bstract]

11. Sykes N, Thorns A: The use of opioids and sedatives at the end of life. Lancet Oncol 4 (5): 312-8,

2003. [PUBMED A bstract]

12. Bercovitch M, Adunsky A: Patterns of high-dose morphine use in a home-care hospice service:

should we be afraid of it? Cancer 101 (6): 1473-7, 2004. [PUBMED A bstract]

13. Coyle N, Adelhardt J, Foley KM, et al.: Character of terminal illness in the advanced cancer

patient: pain and other symptoms during the last four weeks of life. J Pain Symptom Manage 5 (2):

83-93, 1990. [PUBMED A bstract]

14. Anderson SL, Shreve ST: Continuous subcutaneous infusion of opiates at end-of-life. Ann

Pharmacother 38 (6): 1015-23, 2004. [PUBMED A bstract]

15. Mercadante S: Pathophysiology and treatment of opioid-related myoclonus in cancer patients.

Pain 74 (1): 5-9, 1998. [PUBMED A bstract]

16. Núñez-Olarte JM: Opioid-induced myoclonus. European Journal of Palliative Care 2 (4): 146-50,

1995.

17. Hemstapat K, Monteith GR, Smith D, et al.: Morphine-3-glucuronide's neuro-excitatory effects

are mediated via indirect activation of N-methyl-D-aspartic acid receptors: mechanistic studies in

embryonic cultured hippocampal neurones. Anesth Analg 97 (2): 494-505, table of contents,


18. Smith MT: Neuroexcitatory effects of morphine and hydromorphone: evidence implicating the 3-













glucuronide metabolites. Clin Exp Pharmacol Physiol 27 (7): 524-8, 2000. [PUBMED A bstract]

19. Wright AW, Mather LE, Smith MT: Hydromorphone-3-glucuronide: a more potent neuro-excitant

than its structural analogue, morphine-3-glucuronide. Life Sci 69 (4): 409-20, 2001. [PUBMED

A bstract]

20. Sjøgren P, Dragsted L, Christensen CB: Myoclonic spasms during treatment with high doses of

intravenous morphine in renal failure. Acta Anaesthesiol Scand 37 (8): 780-2, 1993. [PUBMED

A bstract]

21. Lee MA, Leng ME, Tiernan EJ: Retrospective study of the use of hydromorphone in palliative care

patients with normal and abnormal urea and creatinine. Palliat Med 15 (1): 26-34, 2001. [PUBMED

A bstract]

22. Klepstad P, Borchgrevink PC, Dale O, et al.: Routine drug monitoring of serum concentrations of

morphine, morphine-3-glucuronide and morphine-6-glucuronide do not predict clinical

observations in cancer patients. Palliat Med 17 (8): 679-87, 2003. [PUBMED A bstract]

23. Gong QL, Hedner J, Björkman R, et al.: Morphine-3-glucuronide may functionally antagonize

morphine-6-glucuronide induced antinociception and ventilatory depression in the rat. Pain 48

(2): 249-55, 1992. [PUBMED A bstract]

24. Sarhill N, Davis MP, Walsh D, et al.: Methadone-induced myoclonus in advanced cancer. Am J

Hosp Palliat Care 18 (1): 51-3, 2001 Jan-Feb. [PUBMED A bstract]

25. Kaiko RF, Foley KM, Grabinski PY, et al.: Central nervous system excitatory effects of meperidine

in cancer patients. Ann Neurol 13 (2): 180-5, 1983. [PUBMED A bstract]

26. Coyne PJ, Viswanathan R, Smith TJ: Nebulized fentanyl citrate improves patients' perception of

breathing, respiratory rate, and oxygen saturation in dyspnea. J Pain Symptom Manage 23 (2):


27. Bruera E, Pereira J: Acute neuropsychiatric findings in a patient receiving fentanyl for cancer

pain. Pain 69 (1-2): 199-201, 1997. [PUBMED A bstract]

28. Nishigaya K, Kaneko M, Nagaseki Y, et al.: Palatal myoclonus induced by extirpation of a

cerebellar astrocytoma. Case report. J Neurosurg 88 (6): 1107-10, 1998. [PUBMED A bstract]

29. Ford B, Pullman SL, Khandji A, et al.: Spinal myoclonus induced by an intrathecal catheter. Mov














Disord 12 (6): 1042-5, 1997. [PUBMED A bstract]

30. Maher J, Choudhri S, Halliday W, et al.: AIDS dementia complex with generalized myoclonus.

Mov Disord 12 (4): 593-7, 1997. [PUBMED A bstract]

31. Werhahn KJ, Brown P, Thompson PD, et al.: The clinical features and prognosis of chronic

posthypoxic myoclonus. Mov Disord 12 (2): 216-20, 1997. [PUBMED A bstract]

32. Wyllie AR, Bayliff CD, Kovacs MJ: Myoclonus due to chlorambucil in two adults with lymphoma.

Ann Pharmacother 31 (2): 171-4, 1997. [PUBMED A bstract]

33. Hyser CL, Drake ME Jr: Myoclonus induced by metoclopramide therapy. Arch Intern Med 143

(11): 2201-2, 1983. [PUBMED A bstract]

34. Pranzatelli MR, Tate ED, Kinsbourne M, et al.: Forty-one year follow-up of childhood-onset

opsoclonus-myoclonus-ataxia: cerebellar atrophy, multiphasic relapses, and response to IVIG.

Mov Disord 17 (6): 1387-90, 2002. [PUBMED A bstract]

35. Batchelor TT, Platten M, Hochberg FH: Immunoadsorption therapy for paraneoplastic

syndromes. J Neurooncol 40 (2): 131-6, 1998. [PUBMED A bstract]

36. Eisele JH Jr, Grigsby EJ, Dea G: Clonazepam treatment of myoclonic contractions associated with

high-dose opioids: case report. Pain 49 (2): 231-2, 1992. [PUBMED A bstract]

37. Cherny N, Ripamonti C, Pereira J, et al.: Strategies to manage the adverse effects of oral

morphine: an evidence-based report. J Clin Oncol 19 (9): 2542-54, 2001. [PUBMED A bstract]

38. Mercadante S, Villari P, Fulfaro F: Gabapentin for opiod-related myoclonus in cancer patients.

Support Care Cancer 9 (3): 205-6, 2001. [PUBMED A bstract]

39. Scullin P, Sheahan P, Sheila K: Myoclonic jerks associated with gabapentin. Palliat Med 17 (8):


40. Zhang C, Glenn DG, Bell WL, et al.: Gabapentin-induced myoclonus in end-stage renal disease.

Epilepsia 46 (1): 156-8, 2005. [PUBMED A bstract]

41. Stayer C, Tronnier V, Dressnandt J, et al.: Intrathecal baclofen therapy for stiff-man syndrome

and progressive encephalomyelopathy with rigidity and myoclonus. Neurology 49 (6): 1591-7,

















42. Bruera E, Sala R, Rico MA, et al.: Effects of parenteral hydration in terminally ill cancer patients: a

preliminary study. J Clin Oncol 23 (10): 2366-71, 2005. [PUBMED A bstract]

43. Bruera E, Schmitz B, Pither J, et al.: The frequency and correlates of dyspnea in patients with

advanced cancer. J Pain Symptom Manage 19 (5): 357-62, 2000. [PUBMED A bstract]

44. Escalante CP, Martin CG, Elting LS, et al.: Dyspnea in cancer patients. Etiology, resource

utilization, and survival-implications in a managed care world. Cancer 78 (6): 1314-9, 1996.

[PUBMED A bstract]

45. Escalante CP, Martin CG, Elting LS, et al.: Identifying risk factors for imminent death in cancer

patients with acute dyspnea. J Pain Symptom Manage 20 (5): 318-25, 2000. [PUBMED A bstract]

46. Ripamonti C: Management of dyspnea in advanced cancer patients. Support Care Cancer 7 (4):


47. Thomas JR, von Gunten CF: Clinical management of dyspnoea. Lancet Oncol 3 (4): 223-8, 2002.

[PUBMED A bstract]

48. Zebraski SE, Kochenash SM, Raffa RB: Lung opioid receptors: pharmacology and possible target

for nebulized morphine in dyspnea. Life Sci 66 (23): 2221-31, 2000. [PUBMED A bstract]

49. Farncombe M, Chater S, Gillin A: The use of nebulized opioids for breathlessness: a chart review.

Palliat Med 8 (4): 306-12, 1994. [PUBMED A bstract]

50. Foral PA, Malesker MA, Huerta G, et al.: Nebulized opioids use in COPD. Chest 125 (2): 691-4,


51. Abernethy AP, McDonald CF, Frith PA, et al.: Effect of palliative oxygen versus room air in relief

of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled

trial. Lancet 376 (9743): 784-93, 2010. [PUBMED A bstract]

52. Booth S, Kelly MJ, Cox NP, et al.: Does oxygen help dyspnea in patients with cancer? Am J Respir

Crit Care Med 153 (5): 1515-8, 1996. [PUBMED A bstract]

53. Booth S, Wade R, Johnson M, et al.: The use of oxygen in the palliation of breathlessness. A report

of the expert working group of the Scientific Committee of the Association of Palliative Medicine.

Respir Med 98 (1): 66-77, 2004. [PUBMED A bstract]















54. Bredin M, Corner J, Krishnasamy M, et al.: Multicentre randomised controlled trial of nursing

intervention for breathlessness in patients with lung cancer. BMJ 318 (7188): 901-4, 1999.

[PUBMED A bstract]

55. Pan CX, Morrison RS, Ness J, et al.: Complementary and alternative medicine in the management

of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain

Symptom Manage 20 (5): 374-87, 2000. [PUBMED A bstract]

56. Yennurajalingam S, Bruera E: Palliative management of fatigue at the close of life: "it feels like my

body is just worn out". JAMA 297 (3): 295-304, 2007. [PUBMED A bstract]

57. Dudgeon DJ, Rosenthal S: Management of dyspnea and cough in patients with cancer. Hematol

Oncol Clin North Am 10 (1): 157-71, 1996. [PUBMED A bstract]

58. Moroni M, Porta C, Gualtieri G, et al.: Inhaled sodium cromoglycate to treat cough in advanced

lung cancer patients. Br J Cancer 74 (2): 309-11, 1996. [PUBMED A bstract]

59. Bennett M, Lucas V, Brennan M, et al.: Using anti-muscarinic drugs in the management of death

rattle: evidence-based guidelines for palliative care. Palliat Med 16 (5): 369-74, 2002. [PUBMED

A bstract]

60. Wildiers H, Menten J: Death rattle: prevalence, prevention and treatment. J Pain Symptom

Manage 23 (4): 310-7, 2002. [PUBMED A bstract]

61. Morita T, Ichiki T, Tsunoda J, et al.: A prospective study on the dying process in terminally ill

cancer patients. Am J Hosp Palliat Care 15 (4): 217-22, 1998 Jul-Aug. [PUBMED A bstract]

62. Kåss RM, Ellershaw J: Respiratory tract secretions in the dying patient: a retrospective study. J

Pain Symptom Manage 26 (4): 897-902, 2003. [PUBMED A bstract]

63. Bennett MI: Death rattle: an audit of hyoscine (scopolamine) use and review of management. J

Pain Symptom Manage 12 (4): 229-33, 1996. [PUBMED A bstract]

64. Spiess JL, Scott SD: Anticholinergic agents for the treatment of "death rattle" in patients with

myasthenia gravis. J Pain Symptom Manage 26 (1): 684-6, 2003. [PUBMED A bstract]

65. Morita T, Tsunoda J, Inoue S, et al.: Risk factors for death rattle in terminally ill cancer patients: a

prospective exploratory study. Palliat Med 14 (1): 19-23, 2000. [PUBMED A bstract]















66. Lawlor PG, Bruera ED: Delirium in patients with advanced cancer. Hematol Oncol Clin North Am

16 (3): 701-14, 2002. [PUBMED A bstract]

67. Breitbart W, Gibson C, Tremblay A: The delirium experience: delirium recall and delirium-related

distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses.

Psychosomatics 43 (3): 183-94, 2002 May-Jun. [PUBMED A bstract]

68. Lawlor PG, Gagnon B, Mancini IL, et al.: Occurrence, causes, and outcome of delirium in patients

with advanced cancer: a prospective study. Arch Intern Med 160 (6): 786-94, 2000. [PUBMED

A bstract]

69. Morita T, Tei Y, Tsunoda J, et al.: Increased plasma morphine metabolites in terminally ill cancer

patients with delirium: an intra-individual comparison. J Pain Symptom Manage 23 (2): 107-13,


70. Morita T, Takigawa C, Onishi H, et al.: Opioid rotation from morphine to fentanyl in delirious

cancer patients: an open-label trial. J Pain Symptom Manage 30 (1): 96-103, 2005. [PUBMED

A bstract]

71. Cohen MZ, Torres-Vigil I, Burbach BE, et al.: The meaning of parenteral hydration to family

caregivers and patients with advanced cancer receiving hospice care. J Pain Symptom Manage 43

(5): 855-65, 2012. [PUBMED A bstract]

72. Centeno C, Sanz A, Bruera E: Delirium in advanced cancer patients. Palliat Med 18 (3): 184-94,


73. Breitbart W, Tremblay A, Gibson C: An open trial of olanzapine for the treatment of delirium in

hospitalized cancer patients. Psychosomatics 43 (3): 175-82, 2002 May-Jun. [PUBMED A bstract]

74. Cowan JD, Palmer TW: Practical guide to palliative sedation. Curr Oncol Rep 4 (3): 242-9, 2002.

[PUBMED A bstract]

75. Morita T, Hirai K, Sakaguchi Y, et al.: Family-perceived distress from delirium-related symptoms

of terminally ill cancer patients. Psychosomatics 45 (2): 107-13, 2004 Mar-Apr. [PUBMED A bstract]

76. Callanan M, Kelley P: Final Gifts: Understanding the Special Awareness, Needs, and

Communications of the Dying. New York, NY: Poseidon Press, 1992.













77. Viscoli C; EORTC International Antimicrobial Therapy Group.: Management of infection in

cancer patients. studies of the EORTC International Antimicrobial Therapy Group (IATG). Eur J

Cancer 38 (Suppl 4): S82-7, 2002. [PUBMED A bstract]

78. Homsi J, Walsh D, Panta R, et al.: Infectious complications of advanced cancer. Support Care

Cancer 8 (6): 487-92, 2000. [PUBMED A bstract]

79. Vitetta L, Kenner D, Sali A: Bacterial infections in terminally ill hospice patients. J Pain Symptom

Manage 20 (5): 326-34, 2000. [PUBMED A bstract]

80. Pereira J, Watanabe S, Wolch G: A retrospective review of the frequency of infections and

patterns of antibiotic utilization on a palliative care unit. J Pain Symptom Manage 16 (6): 374-81,


81. Chen LK, Chou YC, Hsu PS, et al.: Antibiotic prescription for fever episodes in hospice patients.

Support Care Cancer 10 (7): 538-41, 2002. [PUBMED A bstract]

82. Oneschuk D, Fainsinger R, Demoissac D: Antibiotic use in the last week of life in three different

palliative care settings. J Palliat Care 18 (1): 25-8, 2002. [PUBMED A bstract]

83. Nagy-Agren S, Haley H: Management of infections in palliative care patients with advanced

cancer. J Pain Symptom Manage 24 (1): 64-70, 2002. [PUBMED A bstract]

84. White PH, Kuhlenschmidt HL, Vancura BG, et al.: Antimicrobial use in patients with advanced

cancer receiving hospice care. J Pain Symptom Manage 25 (5): 438-43, 2003. [PUBMED A bstract]

85. Clayton J, Fardell B, Hutton-Potts J, et al.: Parenteral antibiotics in a palliative care unit:

prospective analysis of current practice. Palliat Med 17 (1): 44-8, 2003. [PUBMED A bstract]

86. Reinbolt RE, Shenk AM, White PH, et al.: Symptomatic treatment of infections in patients with

advanced cancer receiving hospice care. J Pain Symptom Manage 30 (2): 175-82, 2005. [PUBMED

A bstract]

87. Labovich TM: Selected complications in the patient with cancer: spinal cord compression,

malignant bowel obstruction, malignant ascites, and gastrointestinal bleeding. Semin Oncol Nurs

10 (3): 189-97, 1994. [PUBMED A bstract]

88. Pereira J, Phan T: Management of bleeding in patients with advanced cancer. Oncologist 9 (5):
















89. Hanks-Bell M, Paice J, Krammer L: The use of midazolam hydrochloride continuous infusions in

palliative care. Clin J Oncol Nurs 6 (6): 367-9, 2002 Nov-Dec. [PUBMED A bstract]

Ethical Issues

Nutritional Supplementation

Providing nutrition to patients at the end of life is a very complex and individualized decision. Ideally,

the options for nutrition support for end-of-life care should be discussed in advance, and information on

all nutritional choices and their consequences should be provided to the patient and family. Patients are

best able to make decisions if they are well informed about the possible risks and benefits of artificial

nutrition. Considerations of financial cost, burden to patient and family of additional hospitalizations

and medical procedures, and all potential complications must be weighed against any potential benefit

derived from artificial nutrition support. Supplemental nutrition may be beneficial in the treatment of

advanced cancer, where quality of life would otherwise suffer and death would be caused by

malnutrition rather than the underlying disease, such as in mechanical obstruction or malabsorption

resulting in intolerance of oral intake.[1]

The rationale for providing artificial nutrition at the very end of life is less clear. One study has

concluded that artificial nutrition—specifically, parenteral nutrition—neither influenced the outcome

nor improved the quality of life in terminally ill patients.[2]

The controversial nature of providing artificial nutrition at the end of life has prompted the American

Academy of Hospice and Palliative Medicine (AAHPM) to recommend that individual clinical situations

be assessed using clinical judgment and skill to determine when artificial nutrition is appropriate.

Recognizing that the primary intention of nutrition is to benefit the patient, AAHPM concludes that

withholding artificial nutrition near the end of life may be appropriate medical care if the risks outweigh

the possible benefit to the patient.[3]

The goal of end-of-life care is to relieve suffering and alleviate distressing symptoms. The patient’s needs

and desires must be the focus, with their best interests being the guide for decision making, influenced by

religious, ethical, and compassionate issues.[4-6]

Resuscitation

Broadly defined, resuscitation includes all interventions that provide cardiovascular, respiratory, and

metabolic support necessary to maintain and sustain the life of a dying patient. It is important for

patients, families, and proxies to understand that choices may be made specifying what supportive

measures, if any, should be given preceding death and at the time of death. People often believe that

there is plenty of time to discuss resuscitation and the surrounding issues. However, many dying patients

do not make choices in advance or have not communicated their decisions to their families, proxies, and




the health care team. If these issues are unresolved at the time of end-of-life events, undesired support

and resuscitation may result. Studies suggest that this aggressive care is associated with worse patient

quality of life and worse adjustment to bereavement for loved ones.[7,8]

Narrowly defined, a Do Not Resuscitate (DNR) order instructs health care providers that, in the event of

cardiopulmonary arrest, cardiopulmonary resuscitation (CPR, including chest compressions and/or

ventilations) should not be performed and that natural death be allowed to proceed. DNR orders must be

made before cardiac arrest and may be recommended by physicians when CPR is considered medically

futile or would be ineffective in returning a patient to life. A DNR order may also be made at the

instruction of the patient (or family or proxy) when CPR is not consistent with the goals of care. It is

advisable for a patient who has clear thoughts about these issues to initiate conversations with the health

care team (or appointed health care agents in the outpatient setting) and to have forms completed as

early as possible (i.e., before hospital admission), before the capacity to make such decisions is lost.

Although patients with end-stage disease and their families are often uncomfortable bringing up the

issues surrounding DNR orders, physicians and nurses can tactfully and respectfully address these issues

appropriately and in a timely fashion. Lack of standardization in many institutions may contribute to

ineffective and unclear discussions around DNR orders.[9] (Refer to the PDQ summary on Transitional

Care Planning for more information.)

Ventilator Withdrawal

Fewer patients with advanced cancer will undergo resuscitation and ventilatory support when

discussions regarding goals of care and advance directives begin early in the course of the disease.

However, when advance directives are not available or when the directives are not adequately

communicated, intubation may occur despite low likelihood of survival.

When ventilatory support appears to be medically futile or is no longer consistent with the patient’s (or

family’s or proxy’s) goals of care, ventilator withdrawal to allow death may take place. Extensive

discussions must first take place with patients (if they are able) and family members to help them

understand the rationale for and process of withdrawal. When no advance directive is available and a

patient can no longer communicate, it is helpful to reinterpret in a more realistic light, or reframe for

family members, that they are not making a decision to “pull the plug” for their loved one. Rather, they

are helping the health care team interpret their loved one’s wishes or discontinuing a treatment that is no

longer considered effective. Such reframing is essential to help family members and significant others

understand that the underlying disease process, and not ventilator withdrawal, is the cause of the

patient’s death.[10]

Two methods of withdrawal have been described: immediate extubation and terminal weaning.[11]

Immediate extubation includes providing parenteral opioids for analgesia and sedating agents such as

midazolam, suctioning to remove excess secretions, setting the ventilator to “no assist” and turning off

all alarms, and deflating the cuff and removing the endotracheal tube. Gentle suctioning of the oral

cavity may be necessary, but aggressive and deep suctioning should be avoided. In some cases, patients

may appear to be in significant distress. Analgesics and sedatives should be provided even if the patient

is comatose. Family members and others who are present should be warned that some movements may

occur after extubation, even in patients who are brain dead. Such movements are probably caused by

hypoxia and may include gasping, moving extremities, or sitting up in bed.[12] Immediate extubation is




generally chosen when a patient is brain dead, when a patient is comatose and unlikely to experience any

suffering, or when a patient prefers a more rapid procedure.

Terminal withdrawal entails a more gradual process. Ventilator rate, oxygen levels, and positive end-

expiratory pressure are decreased gradually over a period of 30 minutes to a few hours. A patient who

survives may be placed on a T-piece; this may be left in place, or extubation may proceed. There is some

evidence that the gradual process in a patient who may experience distress allows clinicians to assess

pain and dyspnea and to modify the sedative and analgesic regimen accordingly.[13] In a study of 31

patients undergoing terminal weaning, most patients remained comfortable, as assessed by a variety of

physiologic measures, when low doses of opioids and benzodiazepines were administered. The average

time to death in this study was 24 hours, although two patients survived to be discharged to hospice.[14]

Paralytic agents have no analgesic or sedative effects, and they can mask patient discomfort. These

neuromuscular blockers should be discontinued before extubation. Guidelines suggest that these agents

should never be introduced when the ventilator is being withdrawn; in general, when patients have been

receiving paralytic agents, these agents should be withdrawn before extubation. The advantage of

withdrawal of the neuromuscular blocker is the resultant ability of the health care provider to better

assess the patient’s comfort level and to allow possible interaction between the patient and loved ones.

One notable exception to withdrawal of the paralytic agent is when death is expected to be rapid after the

removal of the ventilator and when waiting for the drug to reverse might place an unreasonable burden

on the patient and family.[15]

Regardless of the technique employed, the patient and setting must be prepared. Monitors and alarms

should be turned off, and life-prolonging interventions such as antibiotics and transfusions should be

discontinued. Family members should be given sufficient time to make preparations, including making

arrangements for the presence of all loved ones who wish to be in attendance. They should be given

information on what to expect during the process; some may elect to remain out of the room during

extubation. Chaplains or social workers may be called to provide support to the family.

Palliative Sedation

Some families may need continuous information and professional guidance when palliative sedation is

used, and this need increases with the duration of the sedation. Individuals or groups outside the family

and health care team may have strong opinions about palliative sedation and may offer unsolicited

guidance that conflicts with what the patient desires. Concerns identified in a study conducted in The

Netherlands relate to the following:[16]

Aim of continuous sedation.

Patient well-being.

Family well-being.

The use of palliative sedation for psychosocial and existential symptoms can be particularly

controversial. The clinician may face many ethical and clinical questions—questions that are more easily

resolved in the case of palliative sedation for pain and physical symptoms. Useful resources include the

framework for the use of sedation in palliative care recommended by the European Association for

Palliative Care [17] and the position statement developed by the American Academy of Hospice and



Palliative Medicine.[18]

For example, the ethical basis for the use of terminal sedation (double effect) is less clearly applicable in

the case of psychiatric symptoms. Under the principle of double effect, the intended effect (relieving

psychological suffering) would be considered allowable as long as any risks or negative effects (i.e.,

shortened survival) are unintended by the health care professional. The difficulty arises because the

principle only discusses the professional’s intention, when it is the patient’s intention that can be unclear

and potentially problematic. Is the depressed patient who no longer wants to suffer depressive

symptoms asking only for that relief, or does the patient also intend to ask the professional to shorten his

or her life? A clinician who feels uncomfortable in such situations may wish to seek guidance from his or

her ethics committee.

Other difficult questions can arise from the potentially negative value that is culturally assigned to

detaching oneself, or “zoning out,” as a lower form of coping. Should the anxious patient who no longer

wants to face the anxiety associated with the end of life and who wants to be sedated be encouraged to

work through such issues? Or is it allowable for these patients to have sedation for dealing with their

anxiety? How many alternatives should be tried before anxiety is considered unacceptable? When

dealing with such requests, professionals should consider their own cultural and religious biases and the

cultural and/or religious backgrounds of patients and their families.

Few studies detail the use of terminal sedation for psychosocial symptoms. Four palliative care programs

in Israel, South Africa, and Spain participated in one survey.[19] One unique study has described the

Japanese experience around the issues of palliative sedation therapy.[20,21] A retrospective study at

the MD Anderson Cancer Center in Houston included 1,207 patients admitted to the palliative care unit.

Palliative sedation was used in 15% of admissions. The most common indications were delirium (82%)

and dyspnea (6%). Sedation in these circumstances is often on a temporary basis and was reversible in

23% of this group of patients.[22]

References

1. McCallum PD, Fornari A: Nutrition in palliative care. In: Elliott L, Molseed LL, McCallum PD,

eds.: The Clinical Guide to Oncology Nutrition. 2nd ed. Chicago, Ill: American Dietetic

Association, 2006, pp 201-7.

2. Torelli GF, Campos AC, Meguid MM: Use of TPN in terminally ill cancer patients. Nutrition 15

(9): 665-7, 1999. [PUBMED A bstract]

3. Statement on Artificial Nutrition and Hydration Near the End of Life. Chicago, Ill: American

Academy of Hospice and Palliative Medicine, 2013. Available online . Last accessed October 14,

2013.

4. Langdon DS, Hunt A, Pope J, et al.: Nutrition support at the end of life: opinions of Louisiana

dietitians. J Am Diet Assoc 102 (6): 837-40, 2002. [PUBMED A bstract]

5. Maillet JO, Potter RL, Heller L: Position of the American Dietetic Association: ethical and legal


http://www.aahpm.org/positions/default/nutrition.html




issues in nutrition, hydration, and feeding. J Am Diet Assoc 102 (5): 716-26, 2002. [PUBMED

A bstract]

6. Balboni TA, Vanderwerker LC, Block SD, et al.: Religiousness and spiritual support among

advanced cancer patients and associations with end-of-life treatment preferences and quality of

life. J Clin Oncol 25 (5): 555-60, 2007. [PUBMED A bstract]

7. Wright AA, Zhang B, Ray A, et al.: Associations between end-of-life discussions, patient mental

health, medical care near death, and caregiver bereavement adjustment. JAMA 300 (14): 1665-


8. Miyashita M, Morita T, Sato K, et al.: Factors contributing to evaluation of a good death from the

bereaved family member's perspective. Psychooncology 17 (6): 612-20, 2008. [PUBMED A bstract]

9. Zhukovsky DS, Hwang JP, Palmer JL, et al.: Wide variation in content of inpatient do-not-

resuscitate order forms used at National Cancer Institute-designated cancer centers in the United

States. Support Care Cancer 17 (2): 109-15, 2009. [PUBMED A bstract]

10. von Gunten CF, Weissman DE: Ventilator Withdrawal Protocol, Part 1, 2nd ed. Milwaukee:

Medical College of Wisconsin, End-of-Life Palliative Education Resource Center, 2005. Available

online . Last accessed October 14, 2013.

11. Marr L, Weissman DE: Withdrawal of ventilatory support from the dying adult patient. J Support

Oncol 2 (3): 283-8, 2004 May-Jun. [PUBMED A bstract]

12. Heytens L, Verlooy J, Gheuens J, et al.: Lazarus sign and extensor posturing in a brain-dead

patient. Case report. J Neurosurg 71 (3): 449-51, 1989. [PUBMED A bstract]

13. Truog RD, Cist AF, Brackett SE, et al.: Recommendations for end-of-life care in the intensive care

unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med 29 (12): 2332-


14. Campbell ML, Bizek KS, Thill M: Patient responses during rapid terminal weaning from

mechanical ventilation: a prospective study. Crit Care Med 27 (1): 73-7, 1999. [PUBMED A bstract]

15. Truog RD, Burns JP, Mitchell C, et al.: Pharmacologic paralysis and withdrawal of mechanical

ventilation at the end of life. N Engl J Med 342 (7): 508-11, 2000. [PUBMED A bstract]

16. van Dooren S, van Veluw HT, van Zuylen L, et al.: Exploration of concerns of relatives during






http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_033.htm








continuous palliative sedation of their family members with cancer. J Pain Symptom Manage 38

(3): 452-9, 2009. [PUBMED A bstract]

17. Cherny NI, Radbruch L; Board of the European Association for Palliative Care.: European

Association for Palliative Care (EAPC) recommended framework for the use of sedation in

palliative care. Palliat Med 23 (7): 581-93, 2009. [PUBMED A bstract]

18. American Academy of Hospice and Palliative Medicine.: Statement on Palliative Sedation.

Chicago, Ill: AAHPM, 2006. Available online . Last accessed October 14, 2013.

19. Fainsinger RL, Waller A, Bercovici M, et al.: A multicentre international study of sedation for

uncontrolled symptoms in terminally ill patients. Palliat Med 14 (4): 257-65, 2000. [PUBMED

A bstract]

20. Morita T, Chinone Y, Ikenaga M, et al.: Ethical validity of palliative sedation therapy: a

multicenter, prospective, observational study conducted on specialized palliative care units in

Japan. J Pain Symptom Manage 30 (4): 308-19, 2005. [PUBMED A bstract]

21. Morita T, Chinone Y, Ikenaga M, et al.: Efficacy and safety of palliative sedation therapy: a

multicenter, prospective, observational study conducted on specialized palliative care units in

Japan. J Pain Symptom Manage 30 (4): 320-8, 2005. [PUBMED A bstract]

22. Elsayem A, Curry Iii E, Boohene J, et al.: Use of palliative sedation for intractable symptoms in

the palliative care unit of a comprehensive cancer center. Support Care Cancer 17 (1): 53-9,


Care During the Final Hours

Although the signs of approaching death may appear obvious to health care professionals, many family

members have never observed the death of a loved one as death has become more institutionalized. As a

result, most people are not familiar with the signs of impending death. Educating family members about

these signs is critical.

In the final days to hours of life, patients often experience a decreased desire to eat or drink, as

evidenced by clenched teeth or turning from offered food and fluids. This behavior may be difficult for

family members to accept because of the meaning of food in our society and the inference that the

patient is “starving.” Family members should be advised that forcing food or fluids can lead to

aspiration. Reframing will include teaching the family to provide ice chips or a moistened oral applicator

to keep a patient’s mouth and lips moist. Massage is another strategy through which family members can

provide care and demonstrate love.



http://www.aahpm.org/positions/default/sedation.html







Patients may withdraw and spend more time sleeping. When patients respond slowly to questions, are

somewhat confused, and have a decreased interest in their environment, family should be encouraged to

touch and speak to them. Professionals can model these behaviors. A patient’s extremities may become

mottled, cold, or cyanotic. The heart rate may increase or decrease and may become irregular; blood

pressure usually drops as death approaches. Urine output may decrease dramatically or cease.

Respiration often takes on an abnormal pattern called Cheyne-Stokes respiration, which ranges from

very shallow breaths to alternating periods of apnea and deep, rapid breathing. These changes should be

explained to family members at the bedside or when they are preparing to care for a loved one at home

It is important for health care professionals to explore with families any fears associated with the time of

death and any cultural or religious rituals that may be important to them. Such rituals might include

placement of the body (e.g., the head of the bed facing Mecca for an Islamic patient) or having only

same-sex caregivers or family members wash the body (as practiced in many orthodox religions). When

death occurs, expressions of grief by those at the bedside vary greatly, dictated in part by culture and in

part by their preparation for the death. Chaplains should be consulted as early as possible if the family

accepts this assistance. Health care providers can offer to assist families in contacting loved ones and

making other arrangements, including contacting a funeral home. (Refer to the PDQ summary on

Spirituality in Cancer Care for more information.)

Grief and Bereavement

Family members are likely to experience loss at the death of their loved one. If left unattended, loss,

grief, and bereavement can become complicated, leading to prolonged and significant distress for either

family members or clinicians. Furthermore, clinicians are at risk for significant grief from the

cumulative effects of many losses through the deaths of their patients. Burnout has also been associated

with unresolved grief in health care professionals. (Refer to the PDQ summary on Grief, Bereavement,

and Coping With Loss for more information.)

Changes to This Summary (12/10/2013)

The PDQ cancer information summaries are reviewed regularly and updated as new information

becomes available. This section describes the latest changes made to this summary as of the date above.

Editorial changes were made to this summary.

This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board,

which is editorially independent of NCI. The summary reflects an independent review of the literature

and does not represent a policy statement of NCI or NIH. More information about summary policies and

the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This

PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.

Questions or Comments About This Summary

If you have questions or comments about this summary, please send them to Cancer.gov through the

http://www.cancer.gov/cancertopics/pdq/supportivecare/spirituality/HealthProfessional

http://www.cancer.gov/cancertopics/pdq/supportivecare/bereavement/HealthProfessional

http://www.cancer.gov/cancertopics/pdq/supportive-care-board

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/Page8#Section_AboutThis_1

http://www.cancer.gov/cancertopics/pdq



Web site’s Contact Form. We can respond only to email messages written in English.

About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-

reviewed, evidence-based information about patient care during the last days to last hours of life. It is

intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide

formal guidelines or recommendations for making health care decisions.

Reviewers and Updates

This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative

Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The

summary reflects an independent review of the literature and does not represent a policy statement of

NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

be discussed at a meeting,

be cited with text, or

replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the

strength of the evidence in the published articles and determine how the article should be included in the

summary.

The lead reviewers for Last Days of Life are:

Larry D. Cripe, MD (Indiana University School of Medicine)

Myra Glajchen, D.S.W. (Beth Israel Medical Center)

David Hui, MD, MSC (M.D. Anderson Cancer Center)

Any comments or questions about the summary content should be submitted to Cancer.gov through the

Web site's Contact Form. Do not contact the individual Board Members with questions or comments

about the summaries. Board members will not respond to individual inquiries.

Levels of Evidence

Some of the reference citations in this summary are accompanied by a level-of-evidence designation.

These designations are intended to help readers assess the strength of the evidence supporting the use of

specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a

formal evidence ranking system in developing its level-of-evidence designations.

http://www.cancer.gov/contact

http://www.cancer.gov/cancertopics/pdq/supportive-care-board


http://www.cancer.gov/cancertopics/pdq/levels-evidence-supportive-care/HealthProfessional



Permission to Use This Summary

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it

cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and

is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ

cancer information summary about breast cancer prevention states the risks succinctly: [include

excerpt from the summary].”

The preferred citation for this PDQ summary is:

National Cancer Institute: PDQ® Last Days of Life. Bethesda, MD: National Cancer Institute. Date last

modified <MM/DD/YYYY>. Available at:

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional. Accessed

<MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within

the PDQ summaries only. Permission to use images outside the context of PDQ information must be

obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about

using the illustrations in this summary, along with many other cancer-related images, is available in

Visuals Online, a collection of over 2,000 scientific images.

Disclaimer

The information in these summaries should not be used as a basis for insurance reimbursement

determinations. More information on insurance coverage is available on Cancer.gov on the Coping with

Cancer: Financial, Insurance, and Legal Information page.

Contact Us

More information about contacting us or receiving help with the Cancer.gov Web site can be found on

our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site’s

Contact Form.

Get More Information From NCI

Call 1-800-4-CANCER

For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer

Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from

8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer

your questions.

Chat online

The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an

Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday

through Friday. Information Specialists can help Internet users find information on NCI Web sites and

answer questions about cancer.

http://www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional

http://visualsonline.cancer.gov/

http://www.cancer.gov/cancertopics/coping/financial-legal

http://www.cancer.gov/help


https://livehelp.cancer.gov/



Write to us

For more information from the NCI, please write to this address:

NCI Public Inquiries Office

9609 Medical Center Dr.

Room 2E532 MSC 9760

Bethesda, MD 20892-9760

Search the NCI Web site

The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites

and organizations that offer support and resources for cancer patients and their families. For a quick

search, use the search box in the upper right corner of each Web page. The results for a wide range of

search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related

to the search term entered.

There are also many other places to get materials and information about cancer treatment and services.

Hospitals in your area may have information about local and regional agencies that have information on

finances, getting to and from treatment, receiving care at home, and dealing with problems related to

cancer treatment.

Find Publications

The NCI has booklets and other materials for patients, health professionals, and the public. These

publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical

trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer

statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or

printed directly from the NCI Publications Locator. These materials can also be ordered by telephone

from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).

http://cancer.gov/

https://pubs.cancer.gov/ncipl

Last Days of Life

Documents

Transcript of Last Days of Life