Supportive and Preventive Medicine

Suggested goals include keeping the respiratory rate at or below 30 breaths/minute and keeping the

patient pain free. Pain assessment should include using the visual analog scale, the BPS, or CPOT

(see the Management of Pain, Agitation, Delirium and Neuromuscular Blockade in Adult Intensive

Care Unit Patients chapter for further details on these scales). Vital signs alone should not be used

for pain assessment.

Never use neuromuscular blocking agents to treat pain.

Morphine is most commonly used; hydromorphone and fentanyl are alternatives.

Morphine should be used cautiously in patients with decreased renal clearance, even at the end

of life, to avoid the risk of accumulation of neuroexcitatory metabolites.

Tolerance may develop over time.

Pain can be improved with correct dosing and titration without causing respiratory depression or

Common symptom in patients at the end of life

Individualize therapy based on underlying cause, patient’s level of consciousness, and level of

sedation.

Oxygen may be used for patients with hypoxia. Corticosteroids, bronchodilators and diuretics may

of dyspnea (J Palliat Med 2012;15:106-14).

No benefit with benzodiazepines unless anxiety is present (Cochrane Database Syst Rev

2010;1:CD007354)

Anxiety/agitation/delirium

Symptoms at the end of life can relate to acute or chronic anxiety, delirium, or terminal delirium.

Nonpharmacologic treatments for agitation and anxiety can include frequent reorientation to the

environment and reduction in noise and other bothersome or stimulating environmental factors.

Haloperidol is an effective agent for delirium-induced agitation, is available as an intravenous

haloperidol may be used without electrocardiographic (ECG) monitoring because the benefits

outweigh the risks of prolonged corrected QT interval, given the goals of care.

Benzodiazepines are the agents of choice for anxiety. Dose is determined by assessing the

patient and increasing the dose as needed (lower initial doses intermittently and titration with

frequent assessment).

ii.

Determining what would be perceived as an acceptable level of sedation with the patient and/

or family or surrogate decision-maker is important before initiating sedatives.

iii.

Tolerance may develop over time.

Fever

Acetaminophen is an effective therapy for improving comfort and decreasing the incidence of

fever. If the patient cannot swallow, this agent may be administered per rectum. If neither enteral

nor rectal access are available, acetaminophen may be administered intravenously.

A nonsteroidal anti-inflammatory drug may be used when acetaminophen is ineffective.

Dexamethasone, which is also known to have antipyretic properties, can be considered.

Nausea and vomiting

Evaluate the patient and determine whether any possible underlying causes (medications, uremia,

gastroparesis, and intestinal or gastric obstruction) can be removed or eliminated.

Agents to consider for symptomatic relief include metoclopramide, haloperidol, risperidone,

ondansetron, and dexamethasone.