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End-of-Life Care

Table of Contents

Overview #

End of life care in hospital ensures that patients are comfortable and free of physical and emotional distress in the period leading up to their death

Key Points

  • Escalate early – junior doctors should not be leading end-of-life discussions or management
  • Communication with family is key

Triage #

If new deterioration – immediately

If patient distressed – immediately

Certifying death – within one hour

Diagnosis #

Goals of patient care and palliative care/end of life care discussions should ideally be conducted by a registrar or consultant early in the illness, during daylight hours and prior to significant deterioration.

  • Junior doctors are not expected to commence these conversations, or to continue them if new issues arise. Always seek help from senior team members if concerned about a patient

Clinical features #

It is important to recognise the terminal phase of illness early, allowing the patient, family and healthcare team to prepare (1, 2). 

  • Communicate early to family, if concerned of immediate deterioration, offer them to come to hospital
  • Know the goals of patient care (GOPC) to determine if deterioration should trigger more active invasive management or active palliative measures

Signs of deterioration towards the terminal phase (1)

  • Progression of disease
  • Worsening of symptoms
  • Increased time asleep
  • Increasingly bed bound
  • Reduced oral intake

Terminal phase (1, 2)

  • Bedbound
  • Minimal verbal response, limited response to stimuli or unconscious
  • No oral intake
  • Changes in breathing pattern
    • Slow or irregular
    • Rapid, shallow
    • Cheyne-stokes breathing (apnoea with rapid breathing between)
    • Agonal breathing (excessive, ineffective efforts to breathe deeply)
    • Noisy/rattling associated with secretions
  • Peripherally shut down (cold hands and feet, pale/mottled skin)

Symptoms to monitor during end-of-life care* (1, 2) 

*this may be a clinical judgement if the patient is unable to communicate

  • Pain
    • Assess for facial expressions/groans when moving or on examination
  • Dyspnoea
    • Increased work of breathing, increased respiratory rate
  • Nausea and vomiting
  • Agitation
  • Oral secretions
    • Usually more distressing for family members, provide reassurance

Investigations #

Once transition to end of life care, no further investigations should be performed, nor vital signs recorded

  • Many hospitals have end-of-life care symptom charts focusing on pain, dyspnoea, nausea, agitation 

Verifying death

If family are present, you may allow some time for them to grieve at the bedside before entering to assess their loved one. Offer your condolences and the option for them to step out of the room while you perform your assessment. 

You should confirm and document the following assessment: 

  • No response to verbal or painful stimuli
  • No carotid pulse
  • Pupils fixed and dilated
  • No breath sounds for 2 mins of auscultation
  • No heart sounds for 2 mins of auscultation

Death certificate

  • Complete the death certificate if you are confident of the cause of death and it is not a Coroners case
  • #If you are unsure of the cause of death, contact a senior clinician

Coroner’s case

  • Common reasons are if the person had a recent surgery or fall prior to death.
  • #If you think the death may be reportable to the Coroner, discuss with the senior treating clinician. If the clinical team is unsure, cases can be discussed with the Coroner’s office.
  • If the death is a Coroners case, do not complete death certificate. Guided by the senior clinician, notify the family of the process involved and that there may be a delay to being able to organise the burial/funeral.
  • Additional information can be found at the Coroners Court website (Victoria): https://www.coronerscourt.vic.gov.au/report-death-or-fire/healthcare-professionals

Management #

General Care (1)

  • Cease all other medications, unless for symptom control
    • Ensure appropriate route, allowing for fluctuations in alertness (e.g., oral and parenteral routes) (4).
    • Consider management of constipation in the setting of prolonged immobility and increased opioid use (4).
  • Mouth care
    • Use swabs (dipped in oral gel or water, or liquid of patient preference) to moisten mouth and lips. The family can assist with this if they would like to contribute to the care of their loved one.
  • Dyspnoea support
    • Some patients find a fan blowing across their face to be helpful.
  • Turning
    • To prevent pressure areas or discomfort.
    • To help with secretion clearance (side lying).
  • Family support
    • Involve faith leaders (e.g., pastor, priest) depending on patient and family preferences (4).
    • Bereavement support services are available. Your social worker can advise on local options.

Pharmacological Management #

Check local hospital protocols for prescribing guidelines and involve your senior clinician before initiating.

Management – pain

Morphine 2.5-5mg subcut Q1H

(1,4)

If renal impairment

Hydromorphone 0.5-1mg subcut Q1H

(1,4)

Management – dyspnoea

If still having oral intake

Ordine 1-2mg PO Q1H

(1,4)

If no oral intake

Morphine 2.5-5mg subcut Q1H

(1,4)

If breathing is distressing with associated agitation

Midazolam 2.5-5mg subcut Q1H OR
Clonazepam 0.2-0.5mg sublingual/subcut Q2H

(1,4)

Management – agitation

Midazolam 2.5-5mg subcut Q1H OR
Clonazepam 0.2-0.5mg sublingual/subcut Q2H

(1,4)

Management – nausea and vomiting

Haloperidol 0.5-1mg subcut Q4H ORMetoclopramide 10mg subcut TDSDo NOT use if associated with bowel obstruction

(1,4)

#Seek assistance if patient has Parkinson’s Disease

  • Levomepromazine, domperidone, ondansetron can be considered (pall care formulary)

Management – secretions

Glycopyrrolate 200-400mcg subcut TDS (max 1200mcg/24hrs)ORHyoscine butylbromide 20mg subcut Q2H (max 120mg/24hrs)

(1,4)

Management – #syringe driver

If regular administration of the above medications is required, discuss with the palliative care team about organising a syringe driver. Ensure nursing staff on the ward can manage these. 

  • Commencement and appropriate dosing should be discussed with senior team members.
  • The continuous ‘background’ infusion doses are usually prescribed in the syringe driver with breakthrough medications to remain on the chart as above.
    • If not on regular medications for symptom relief, often the amount (or slightly less) of PRN used in the last 24hrs will be added to the syringe driver
    • Don’t forget to calculate conversion of oral to subcut for dosing and compatibility of medications (4)

References #

  1. eTG Complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2016. Terminal care: care in the last days of life [updated 2021 Mar; cited 2021 Oct 2]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=terminal-care-in-last-days-of-life&sectionId=pcg4-c26-s8#toc_d1e104
  2. Harman SM, Bailey FA, Walling AM. Palliative care: The last hours and days of life. UpToDate. [Internet]. UpToDate; 2020 [updated 2020 Aug 05; cited 2021 Oct 2]. Available from: https://www.uptodate.com/contents/palliative-care-the-last-hours-and-days-of-life?search=end%20of%20life%20care&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H3528112219
  3. University of Wollongong. Palliative Care Outcomes Collaboration [Internet]. Wollongong. 2020 [cited 2021 Oct 2]. Available from: https://www.uow.edu.au/ahsri/pcoc/ 
  4. Palliative care formulary [internet]. Royal Pharmaceutical Company; 2021. Available from: https://www.medicinescomplete.com.acs.hcn.com.au/#/browse/palliative

  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Jessica Reece

Dr Paula Loveland

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