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Martinsson L, Strang P, Lundström S, Hedman C. Parenteral Hydration in Dying Patients With Cancer: A National Registry Study. J Pain Symptom Manage 2024; 67:384-392. [PMID: 38342476 DOI: 10.1016/j.jpainsymman.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/24/2024] [Accepted: 01/30/2024] [Indexed: 02/13/2024]
Abstract
CONTEXT Clinically assisted hydration during end-of-life care among patients with cancer is controversial; practice varies between clinical settings and countries, and there is a lack of evidence. OBJECTIVES To examine whether breathlessness, respiratory secretion, or confusion correlates with receiving parenteral hydration during end of life, adjusted for sex, age, and place of death. METHODS The Swedish Register of Palliative Care database was used to collect data about the usage of parenteral hydration during the last day of life, and the occurrence of three symptoms during the last week. Adults dying from cancer during 2011-2021 in hospitals, in residential care homes, and within specialized palliative care were included. Correlation between parenteral hydration and symptoms was examined using χ2-test and logistic regression. RESULTS A total of 147,488 patients were included in the study. Parenteral hydration was more often prescribed to younger persons, to men, and in acute hospitals (compared to other settings), p < 0.001 in all three comparisons. Patients with hematological malignancies (20%) and ovarian cancer (16%) were most likely to receive parenteral hydration, while those with brain tumors (6%) were least likely. The presence of all three analyzed symptoms during the last week (breathlessness, respiratory secretion, and confusion) were significantly correlated with having received parenteral hydration during the last day of life (p < 0.001). In the final logistic regression model adjusted for age, sex, and place of death, the only symptom with remaining correlation to parenteral hydration was breathlessness (OR 1.56, 95% CI 1.50-1.6). CONCLUSION There is an association between parenteral hydration and increased breathlessness in patients with cancer. Provision of parenteral hydration is more prevalent in men, younger patients, and those with hematological malignancies or ovarian cancer, and most widespread in acute hospital settings.
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Affiliation(s)
- Lisa Martinsson
- Department of Radiation Sciences, Oncology (L.M.), Umeå University, Umeå, Sweden.
| | - Peter Strang
- Department of Oncology-Pathology (P.S., S.L.), Karolinska Institutet, Stockholm, Sweden; R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Staffan Lundström
- Department of Oncology-Pathology (P.S., S.L.), Karolinska Institutet, Stockholm, Sweden; R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden
| | - Christel Hedman
- R & D Department (P.S., S.L., C.H.), Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Molecular Medicine and Surgery (C.H.), Karolinska Institutet, Stockholm, Sweden; Department of Clinical Sciences Lund (C.H.), Lund University, Lund, Sweden
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Oda S, Kawakami A, Ashida K, Tanaka M. Death rattle: palliative nursing practices Delphi study. BMJ Support Palliat Care 2024:spcare-2024-004887. [PMID: 38565275 DOI: 10.1136/spcare-2024-004887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Interventions for patients with death rattle remain under consideration, and their families strongly acknowledge the need for improved care. However, few reports exist concerning specific and comprehensive nursing practices for them. This study aimed to clarify nursing practices for patients with death rattle and their families in hospital wards and examine each practice's importance. METHODS We used a modified Delphi method with expert nurses with extensive experience in end-of-life care. Participants were recruited using convenience and snowball sampling. First, we developed a list of nursing practices through a literature review and individual interviews. Second, we conducted the Delphi survey. Two rounds of judging were performed. Items were rated on a 9-point Likert scale (1=not important at all to 9=very important). An item was considered 'important' if at least 80% of the participants rated it ≥7. RESULTS The list comprised 40 items across 8 domains: assessment of death rattle and the distress felt by the patients, oral care, repositioning, adjustment of parenteral hydration, suctioning, administration of alleviating medications, communication with and assessment of family members who witness death rattle, and nurse's attitude towards death rattle and the relevant interventions. Of the 46 recruited experts, 42 participated in both rounds. Participants regarded 37 of the 40 items as important. CONCLUSIONS This study specifically and comprehensively identified nursing practices for patients with death rattle and their families using a modified Delphi method to support clinical nursing practice and improve the quality of care.
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Affiliation(s)
- Sumika Oda
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
| | - Aki Kawakami
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
| | - Kaoru Ashida
- Department of Nursing, Kanto Gakuin University, Yokohama, Japan
| | - Makoto Tanaka
- Department of Adult Health Nursing, Graduate School of Health Care Sciences, Tokyo Medical and Dental University (TMDU), Bunkyo-ku, Japan
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Yamaguchi T, Yokomichi N, Yamaguchi T, Maeda I, Matsunuma R, Tanaka-Yagi Y, Akatani A, Suzuki K, Kohara H, Taniyama T, Matsuda Y, Nakajima N, Morita T, Tsuneto S, Mori M. Anticholinergic drugs for death rattle in dying patients with cancer: multicentre prospective cohort study. BMJ Support Palliat Care 2023; 13:462-471. [PMID: 36357162 DOI: 10.1136/spcare-2022-003823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/28/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND This study aimed to investigate the effectiveness of anticholinergics (AC) for death rattle in dying patients with cancer. METHODS This is a prospective cohort study enrolled Terminally ill adult (20 years or older) patients with cancer who developed substantial death rattle (Back score ≥2) from 23 palliative care units in Japan. AC treatment for death rattle was prescribed according to primary physician's decision. The primary outcome was the proportion of patients whose death rattle improved, which was defined as a Back score of ≤1. We compared the proportion of improved cases in patients treated with (AC group) and without (non-AC group) AC, controlling potential confounders by employing propensity score weighting. RESULTS Of the 1896 patients enrolled, we included 196 who developed a substantial death rattle. Of these, 81 received AC. 56.8% in the AC group and 35.4% in the non-AC group had an improved death rattle at 8 hours after baseline. In the weighted analysis, AC group showed significant improvements in death rattle, with an adjusted OR of 4.47 (95% CI 2.04 to 9.78; p=0.0024). All sensitivity analyses achieved essentially the same results. In the subgroup analysis, ACs were strongly associated with death rattle improvement in men, patients with lung cancer, and type 1 death rattle (adjusted OR 5.81, 8.38 and 9.32, respectively). CONCLUSIONS In this propensity score-weighted analysis, ACs were associated with death rattle improvement in terminally ill patients with cancer who developed substantial death rattle. TRIAL REGISTRATION NUMBER UMIN-CTR (UMIN00002545).
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Affiliation(s)
- Takashi Yamaguchi
- Department of Palliative Medicine, Kobe University Graduate School of Medicine School of Medicine, Kobe, Hyogo, Japan
| | - Naosuke Yokomichi
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri Chuo Hospital, Toyonaka, Osaka, Japan
| | - Ryo Matsunuma
- Department of Palliative Care, Konan Medical Center, Kobe, Hyogo, Japan
| | | | - Asami Akatani
- Department of Palliative Medicine, Kobe University Graduate School of Medicine School of Medicine, Kobe, Hyogo, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Kohara
- Department of Palliative Care, Hatsukaichi Memorial Hospital, Hatsukaichi, Hiroshima, Japan
| | - Tomohiko Taniyama
- Department of Oncology and Palliative Care, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Yosuke Matsuda
- Department of Palliative Care, St Luke's International University, Chuo-ku, Tokyo, Japan
| | - Nobuhisa Nakajima
- Division of Community Medicine and Internal Medicine, University of the Ryukyus Hospital, Nishihara, Okinawa, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Kyoto University, Kyoto, Japan
| | - Masanori Mori
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
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Taburee W, Dhippayom T, Nagaviroj K, Dilokthornsakul P. Effects of Anticholinergics on Death Rattle: A Systematic Review and Network Meta-Analysis. J Palliat Med 2023; 26:431-440. [PMID: 36194053 DOI: 10.1089/jpm.2022.0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Anticholinergics have been used to treat death rattle (DR) in dying patients with palliative care. However, the effect of anticholinergics is still controversial. No quantitative summary of their effects is reported. Objective: This study aimed to systematically review and quantitatively synthesize the effect of anticholinergics on DR treatment and prophylaxis. Design: A systematic search was performed in the electronic databases (PubMed, Embase®, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) from inception to October 2021. Studies conducted to determine the effect of anticholinergics compared with other anticholinergics or placebo on noise reduction score in dying patients were included. A network meta-analysis was performed for DR treatment. The effect of anticholinergics at four hours was assessed. A pairwise meta-analysis was performed for DR prophylaxis. Results: A total of nine studies were included with 1103 patients. Six studies were randomized controlled trials, and three studies were cohort studies. Seven studies were conducted for DR treatment, while two studies were conducted for DR prophylaxis. For DR treatment, no statistically significant difference was observed between each anticholinergic (hyoscine hydrobromide, hyoscine butyl bromide, atropine, and glycopyrrolate) and placebo and among any anticholinergics. However, the surface under cumulative ranking curve indicated that hyoscine butyl bromide had the highest surface under the cumulative ranking curve (SUCRA) with 71.3%. For DR prophylaxis, the relative risk of DR occurrence for hyoscine butyl bromide was 0.23 (0.04, 1.18; I2 = 84.5%) compared with no treatment. Conclusion: This study showed no strong evidence of the regular use of anticholinergics for DR treatment. In addition, hyoscine butyl bromide appears to have a high potential for DR prophylaxis.
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Affiliation(s)
- Watcharaporn Taburee
- Department of Family Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Teerapon Dhippayom
- The Research Unit of Evidence Synthesis (TRUES), Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Kittiphon Nagaviroj
- Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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Ijaopo EO, Zaw KM, Ijaopo RO, Khawand-Azoulai M. A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness. Gerontol Geriatr Med 2023; 9:23337214231183243. [PMID: 37426771 PMCID: PMC10327414 DOI: 10.1177/23337214231183243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/23/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.
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Affiliation(s)
| | - Khin Maung Zaw
- University of Miami Miller School of Medicine, FL, USA
- Miami VA Medical Center, FL, USA
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Jeon SY, Choe YH, Song EK, Yim CY, Lee NR. Foreign body removal using flexible bronchoscopy in terminal cancer: A case report. Medicine (Baltimore) 2021; 100:e27620. [PMID: 34713848 PMCID: PMC8556047 DOI: 10.1097/md.0000000000027620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/13/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Pulmonary foreign body aspiration is a serious medical problem. The risk of foreign body aspiration into the airways increases considerably in patients with end stage cancer with reduced consciousness and impaired airway reflexes. However, few studies have reported on foreign body aspiration in the airways in patients with terminal cancer or receiving end-of-life care. Herein, we report the use of flexible bronchoscopy in patients with end-of-life cancer with pulmonary aspiration. PATIENT CONCERNS A 71-year-old man with neuroendocrine carcinoma was admitted to a palliative care unit for end-of-life care. He accidentally aspirated implant teeth into the airway with decreased consciousness and death rattle. DIAGNOSIS On chest x-ray, the foreign material was observed in the left main bronchus. INTERVENTIONS Despite concerns regarding the use of bronchoscopy given the deterioration of the overall organ function, flexible bronchoscopy was performed. OUTCOMES Eventually, the foreign body was removed using a basket in the nasal cavity without major complications. The patient died comfortably after 7 days. LESSONS The possibility of patients in the palliative care unit with reduced consciousness and death rattle to aspirate foreign bodies into the airways must be carefully considered. Flexible bronchoscopy should be considered to carefully remove aspirated foreign bodies in the airway without any side effects, even in patients with terminal cancer or receiving end-of-life care.
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Affiliation(s)
- So-Yeon Jeon
- Division of Hematology and Oncology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine, Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Yeong-Hun Choe
- Research Institute of Clinical Medicine, Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
- Division of Respiratory medicine and Allergy, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea
| | - Eun-Kee Song
- Division of Hematology and Oncology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine, Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Chang-Yeol Yim
- Division of Hematology and Oncology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine, Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
| | - Na-Ri Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea
- Research Institute of Clinical Medicine, Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Republic of Korea
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7
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Matsunuma R, Suzuki K, Matsuda Y, Mori M, Watanabe H, Yamaguchi T. Palliative care physicians' perspectives of management for terminally ill cancer patients with death rattle: a nationwide survey. Jpn J Clin Oncol 2020; 50:830-833. [PMID: 32419027 DOI: 10.1093/jjco/hyaa044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/14/2020] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
Death rattle occurs during the last days of life, and relatives of those afflicted frequently report that it is very distressful. However, there is no effective treatment for it. The purpose of this study was to investigate the perceptions of Japanese palliative care physicians in clinical practice in Japan. We conducted a nationwide survey of 268 physicians via an anonymous, self-report questionnaire. We assessed pharmacological and non-pharmacological management and anticholinergic agent choice. One hundred eighty-nine physicians (70.5%) returned the questionnaires. Fifty-five participants (29.1%) treating patients with Type-1 (real death rattle) and 36 participants (19%) treating patients with Type-2 (pseudo-death rattle) death rattle reported that they would frequently administer an anticholinergic agent. One-fourth would administer scopolamine butylbromide or scopolamine hydrobromide. In conclusion, more Japanese palliative care physicians thought that anticholinergic agents might be effective for treating Type-1 death rattle rather than Type-2. Further clinical trials of these agents are needed.
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Affiliation(s)
- Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer, and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
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Dayan D, Menahem S, Shvartzman P. When they stop drinking-examining end-of-life hydration practices and death rattle occurrence. Support Care Cancer 2020; 29:179-185. [PMID: 32328774 DOI: 10.1007/s00520-020-05470-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/13/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE To characterize the practice of subcutaneous hydration provision in the Beer-Sheva home care hospice unit. We also explore the potential connection between the provision of subcutaneous hydration and the incidence of death rattle. METHODS This was a prospective observational study involving 120 hospice patients. During the 6 days before death, hospice staff recorded whether or not fluids were administered orally and/or subcutaneously; the duration, timing, and quantity of fluid administration; the incidence, timing, and duration of death rattle; and whether medications that can affect death rattle were given. RESULT Fifty-three percent of the patients received subcutaneous hydration. The mean daily volume administered in the hydration group was 434 ml. There was a significant association between the duration of treatment in the hospice unit and provision of subcutaneous hydration (mean of 51 days in hydration group vs. 31 days in non-hydration group, p = 0.03). Although not statistically significant, males were more likely to receive subcutaneous hydration than females (62% of males vs. 46% of females, p = 0.09). There was a higher incidence of death rattle in men compared to women (54.7% in men vs. 32.8% in women, p = 0.025). A statistically significant association between death rattle and the provision of subcutaneous hydration wasn't demonstrated. CONCLUSION The decision of whether to provide subcutaneous hydration is individualized taking into consideration the values of the patients and their families. The provision of 500 ml per day of subcutaneous saline during the last 6 days of life does not significantly increase the incidence of death rattle.
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Affiliation(s)
- Daniel Dayan
- Department of Family Medicine, Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, 84105, Beer-Sheva, Israel. .,Clalit Health Services, South District, Beer-Sheva, Israel.
| | - Sasson Menahem
- Department of Family Medicine, Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, 84105, Beer-Sheva, Israel.,Clalit Health Services, South District, Beer-Sheva, Israel.,Pain and Palliative Care Unit, Siaal Research Center for Family Medicine and Primary Care, Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Pesach Shvartzman
- Clalit Health Services, South District, Beer-Sheva, Israel.,Pain and Palliative Care Unit, Siaal Research Center for Family Medicine and Primary Care, Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Abstract
Although dehydration is a serious condition associated with significant morbidity and mortality in palliative care patients, as in any other patient group, treatment remains controversial. A narrative review of the causes of dehydration during end of life was conducted paying special attention to the nature of terminal dehydration. A comprehensive search of the literature was performed to identify relevant articles published in English and German languages between 1960 and 2018. Currently available options for bed-side evaluation and therapeutic approaches were critically appraised and areas of future research are emphasized. The following inferences can be derived: 1) the available evidence does not support a clear decision in favor or against fluid therapy during the dying phase. 2) There is inadequate precision of the term end of life care (ELC) and insufficient differentiation between modes of dehydration of palliative care patients. 3) Evaluation of dehydration based on its clinical appearance is considered the method of choice compared to invasive procedures. 4) Detailed clinical assessment of symptom reversibility in terminal dehydration by an appropriate fluid challenge is mandatory in the decision-making process. 5) If despite adequate rehydration measures, complete reversibility of the clinical picture of dehydration can no longer be achieved since organ systems are gradually deteriorating, the cessation of clinically assisted hydration (CAH) can be considered. 6) If symptoms of dehydration are reversible after fluid challenge and no other patient wishes to the contrary are known, fluid management should be continued in the context of symptom control. 7) Hyperhydration represents a considerable threat during fluid management that needs to be prevented by noninvasive monitoring procedures. In conclusion, if CAH is applied as a part of ELC the hydration status needs to be individually appraised and all therapeutic measures constantly need to be adapted to the findings of diligent monitoring procedures.
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Affiliation(s)
- U Suchner
- Department of anesthesiology and intensive care, Klinikum Darmstadt, Darmstadt, Germany
| | | | - C Gog
- Palliative care section, Sana-Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach, Germany.
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Hindmarsh J, Everett P, Hindmarsh S, Lee M, Pickard J. Glycopyrrolate and the Management of "Death Rattle" in Patients with Myasthenia Gravis. J Palliat Med 2020; 23:1408-1410. [PMID: 31976808 DOI: 10.1089/jpm.2019.0598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Death rattle commonly occurs at the end of life and is typically managed with anticholinergic agents. Myasthenia gravis is an autoimmune disorder characterized by fatigability of skeletal muscle, resulting from autoimmune destruction of acetylcholine receptors at the motor endplate. The condition is treated with acetylcholinesterase inhibitors, which potentiate the action of acetylcholine. Agents that antagonize acetylcholine activity (e.g., anticholinergic agents, such as glycopyrrolate) can, therefore, exacerbate myasthenia gravis. We discuss the case of a patient dying with myasthenia gravis that developed problematic "death rattle," and the successful use of glycopyrrolate in treating this symptom.
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Affiliation(s)
- Jonathan Hindmarsh
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom.,Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Paul Everett
- Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Sharlene Hindmarsh
- Department of Pharmacy, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Mark Lee
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom
| | - Jonathan Pickard
- Inpatient Unit, Specialist Centre for Palliative Care, St. Benedict's Hospice, Sunderland, United Kingdom
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11
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Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020; 24:435-444. [PMID: 32863637 PMCID: PMC7435102 DOI: 10.5005/jp-journals-10071-23400] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation. How to cite this article: Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020;24(6):435–444.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Mahe, Manipal, Karnataka, India
| | - Raj Kumar Mani
- Department of Critical Care and Pulmonology, Batra Hospital and Medical Research Centre, Delhi, India
| | - Roop Gursahani
- Department of Neurology, PD Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
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Yeow ME, Chen E. Ventilator Withdrawal in Anticipation of Death: The Simulation Lab as an Educational Tool in Palliative Medicine. J Pain Symptom Manage 2020; 59:165-171. [PMID: 31610274 DOI: 10.1016/j.jpainsymman.2019.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/18/2022]
Abstract
Simulation is a growing model of education in many medical disciplines. Withdrawal of mechanical ventilation is an important skill set for palliative medicine practitioners who must be facile with a variety of end-of-life scenarios and is well suited to the simulation laboratory. We describe a novel approach using high-fidelity simulation to design a curriculum to teach Hospice & Palliative Medicine fellows the practical aspects of managing a compassionate terminal extubation. This simulation session aims to equip palliative fellows with a knowledge base of respiratory physiology and mechanical ventilation as well as the practical experience of performing a terminal extubation. We designed a three-hour simulation session which includes a one-hour didactic followed by two hours of simulation, with four cases that focus on different teaching points regarding symptom management and practical aspects of removing the endotracheal tube. The session was designed as an annual session for Hospice & Palliative Medicine fellows in our region during a collaborative educational conference. Based on feedback, the session is scheduled for the beginning of the academic year and each fellow is given the opportunity to physically remove the endotracheal tube. Simulation can be effectively used to teach practical and complex bedside skills such as withdrawal of mechanical ventilation to palliative medicine trainees. This method of teaching could be expanded to teach other advanced hospice and palliative care skills.
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Affiliation(s)
- Mei-Ean Yeow
- Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Elaine Chen
- Division of Pulmonary & Critical Care Medicine and Section of Palliative Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Hsu Y, Chu F, Chen T, Chou L, Chang H, Lin M, Hwang S. Lots of little ones: Analysis of charitable donations to a hospice and palliative care unit in Taiwan. Int J Health Plann Manage 2019; 34:e1810-e1819. [DOI: 10.1002/hpm.2897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 08/13/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Ya‐Chuan Hsu
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Feng‐Yuan Chu
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
| | - Tzeng‐Ji Chen
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Li‐Fang Chou
- Department of Public Finance National Chengchi University Taipei Taiwan
| | - Hsiao‐Ting Chang
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Ming‐Hwai Lin
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
| | - Shinn‐Jang Hwang
- Department of Family Medicine Taipei Veterans General Hospital Taipei Taiwan
- School of Medicine National Yang‐Ming University Taipei Taiwan
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Suchner U, Reudelsterz C, Gog C. ["Terminal" dehydration : Differential diagnosis and body of evidence]. Med Klin Intensivmed Notfmed 2019; 114:355-368. [PMID: 30968188 DOI: 10.1007/s00063-019-0583-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Dehydration in palliative care patients can be associated with increased morbidity and mortality and is nevertheless therapeutically controversial. This article provides an overview of possible causes of dehydration at the end of life and places special emphasis on "terminal" dehydration in the dying. Empirical attitudes of healthcare professionals and persons concerned (patients and relatives) as well as evidence-based findings on "terminal" dehydration are elucidated and the limitations are described. Finally, it is concluded that the appropriate detection of the mode of dehydration (including its underlying pathophysiology) as well as the clinical evaluation of the "reversibility" of the symptoms after fluid therapy, is of central importance in establishing the indications for clinically assisted hydration (CAH).
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Affiliation(s)
- U Suchner
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Darmstadt, Darmstadt, Deutschland
| | | | - C Gog
- Sektion Palliativmedizin, Sana-Klinikum Offenbach, Starkenburgring 66, 63069, Offenbach, Deutschland.
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Mercadante S, Marinangeli F, Masedu F, Valenti M, Russo D, Ursini L, Massici A, Aielli F. Hyoscine Butylbromide for the Management of Death Rattle: Sooner Rather Than Later. J Pain Symptom Manage 2018; 56:902-907. [PMID: 30172864 DOI: 10.1016/j.jpainsymman.2018.08.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Death rattle (DR) is a dramatic sign in the dying patient. Existing studies with anticholinergic agents are controversial, as this class of drugs has been commonly administered without considering the rationale of the mechanism of action. A meaningful use of these drugs may provide a better outcome. OBJECTIVES The aim of this study was to assess the efficacy of hyoscine butylbromide (HB), given prophylactically in comparison with HB administered once DR occurs. METHODS Dying patients having a score of ≥3 in the Richmond Agitation-Sedation Scale-palliative version were included in the study. HB (60 mg/day) was given when DR occurred (Group 1) or as pre-emptive treatment (Group 2). The onset of DR (death rattle free time) and intensity of DR were recorded at intervals until death. RESULTS Eighty-one and 51 patients were randomized to Group 1 and 2, respectively. Patients in Group 2 survived longer than those in Group 1 (P < 0.05). DR occurred in 49 (60.5%) and three patients (5.9%) in Group 1 and 2, respectively (P = 0.001). A significant difference in the number of patients reporting DR was found at intervals examined (30 minutes, one hour, and then every six hours until death [P = 0.001]). In Group 1 and 2, DR free time was 20.4 (20.5) and 27.3 hours (25.2), respectively (P = 0.001). In Group 1, the treatment was considered effective in 10 patients (20.4%) only, after a mean of 14.4 hours (SD 8.57). CONCLUSION The prophylactic use of HB is an efficient method to prevent DR, whereas the late administration produces a limited response, confirming data from traditional studies performed with anticholinergics. This could be considered a new paradigm to manage a difficult and dramatic sign, such as DR.
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Affiliation(s)
- Sebastiano Mercadante
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Sicily, Italy.
| | - Franco Marinangeli
- Department of Life Health and Environmental Sciences, Anesthesiology and Pain Medicine, University of L'Aquila, L'Aquila, Italy
| | - Francesco Masedu
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Department of Biotechnological and Applied Clinical Sciences, Section of Clinical Epidemiology and Environmental Medicine, University of L'Aquila, L'Aquila, Italy
| | | | - Laura Ursini
- "Casa Margherita" Hospice, ASL 01 Avezzano-Sulmona-L'Aquila, L'Aquila, Italy
| | | | - Federica Aielli
- Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, L'Aquila, Italy
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Suchner U, Reudelsterz C, Gog C. „Terminale“ Dehydratation, Teil 1. Anaesthesist 2018; 67:709-722. [DOI: 10.1007/s00101-018-0480-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kolb H, Snowden A, Stevens E, Atherton I. A retrospective medical records review of risk factors for the development of respiratory tract secretions (death rattle) in the dying patient. J Adv Nurs 2018; 74:1639-1648. [DOI: 10.1111/jan.13704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Austyn Snowden
- School of Health and Social Care; Napier University; Edinburgh UK
| | - Elaine Stevens
- School of Health Nursing and Midwifery; University of the West of Scotland; Paisley UK
| | - Iain Atherton
- School of Health and Social Care; Napier University; Edinburgh UK
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Kolb H, Snowden A, Stevens E. Systematic review and narrative summary: Treatments for and risk factors associated with respiratory tract secretions (death rattle) in the dying adult. J Adv Nurs 2018; 74:1446-1462. [DOI: 10.1111/jan.13557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 02/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
| | - Austyn Snowden
- School of Health and Social Care; Edinburgh Napier University; Edinburgh UK
| | - Elaine Stevens
- Adult Health; University of the West of Scotland; Paisley UK
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Likar R, Michenthaler MC, Traar R, Molnar M, Neuwersch S. Clinical factors influencing death rattle breathing in palliative care cancer patients : Non-interventional study. Z Gerontol Geriatr 2016; 50:332-338. [PMID: 27245228 DOI: 10.1007/s00391-016-1042-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 01/14/2016] [Accepted: 02/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIM In the last days of life the clinical symptom of death rattle breathing is manifested in many awake or semiconscious patients in palliative care. Scientific studies on relevant influencing factors on the characteristics of the clinical symptom of death rattle breathing in patients in palliative care are rare. MATERIAL AND METHODS The design of the study is based on a non-interventional prospective study with questionnaire evaluation and was implemented at the palliative care unit at the Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care at the Clinical Center Klagenfurt, Austria. The questionnaire was developed by the authors of this study. RESULTS The study had a predefined duration of 10 months (from February to November 2012) and during this period a total of 273 patients were admitted to the palliative care unit of the Clinical Center in Klagenfurt. Of these 105 (38.5 %) died and could therefore be included in the evaluation but 3 patients in palliative care (2.9 %) did not fulfil the inclusion criteria of a malignant disease. In total 102 patients, 43 females (42.2 %) and 59 males (57.9 %) were evaluated. The average age was 69 years with a range of 41-92 years. The largest proportion of the random sample (62.8 %) was in the patient age group from 61 to 80 years old and death rattle breathing could be observed in 26 patients (25.3 %) of the total sample. In a specific subgroup analysis regarding the intensity of the symptom, many of the affected patients suffered noisy breathing or severe death rattle breathing. In these cases it was primarily women in the group of patients with death rattle breathing. Gender was found to be a statistically relevant influencing factor (p = 0.034) on the intensity of the symptom. CONCLUSION The great majority of the variables studied showed no influence on the development of the symptom of death rattle breathing; however, more intensive forms were manifested in female patients. The small study population could be a limitation of the present study although the prospective design allows valid conclusions to be drawn. In the future studies should be implemented in order to improve treatment of patients suffering from death rattle breathing.
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Affiliation(s)
- Rudolf Likar
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt, Feschnigstrasse 11, 9020, Klagenfurt, Austria.
| | - Manuela Christine Michenthaler
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt, Feschnigstrasse 11, 9020, Klagenfurt, Austria
| | - Romana Traar
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt, Feschnigstrasse 11, 9020, Klagenfurt, Austria
| | - Mario Molnar
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt, Feschnigstrasse 11, 9020, Klagenfurt, Austria
| | - Stefan Neuwersch
- Center for Interdisciplinary Pain Therapy, Oncology and Palliative Care, Klinikum Klagenfurt, Feschnigstrasse 11, 9020, Klagenfurt, Austria
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Cloyes KG, Berry PH, Martz K, Supiano K. Characteristics of Prison Hospice Patients. JOURNAL OF CORRECTIONAL HEALTH CARE 2015; 21:298-308. [DOI: 10.1177/1078345815588842] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Kim Martz
- Boise State University, Boise, ID, USA
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Shimizu Y, Miyashita M, Morita T, Sato K, Tsuneto S, Shima Y. Care strategy for death rattle in terminally ill cancer patients and their family members: recommendations from a cross-sectional nationwide survey of bereaved family members' perceptions. J Pain Symptom Manage 2014; 48:2-12. [PMID: 24161372 DOI: 10.1016/j.jpainsymman.2013.07.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 07/13/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Bereaved family members witnessing a patient's death rattle often experience distress. However, the benefits of specific care measures aimed at decreasing death rattle-associated family distress have not yet been evaluated. OBJECTIVES To clarify death rattle-related emotional distress levels among family members and their perceptions of the need for death rattle care improvement and explore the factors influencing both these issues. METHODS A cross-sectional questionnaire survey of bereaved family members of cancer patients was conducted in 95 palliative care units in June 2007. RESULTS Six hundred sixty-three questionnaires were mailed out, and 390 (61%) responses were analyzed. Among these, 181 (46%) respondents experienced death rattle. Of these, 66% reported high distress levels and 53% perceived a strong need for improved death rattle care. Factors influencing high distress levels were the gender (female) of family members, unawareness about death rattle being a natural phenomenon, and their fear and distressing interpretations of death rattle. Factors influencing perceptions of a strong need for improved care were the gender (male) of family members, severity of death rattle, death rattle-associated discomfort to patients, family members' experiences of inadequate nursing care (e.g., repositioning) and insufficient consultation about suctioning, and their perception of uncomfortable smells. CONCLUSION To decrease family-perceived distress, medical staff should alleviate patient symptoms and suffering with a comprehensive care strategy, try to decrease uncomfortable smells, and communicate with family members to address distressing interpretations and fears.
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Affiliation(s)
- Yoichi Shimizu
- Department of Nursing, National Cancer Center Hospital, Tokyo, Japan.
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team and Seirei Hospice, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | - Kazuki Sato
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoru Tsuneto
- Department of Palliative Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasuo Shima
- Department of Palliative Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
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Mercadante S, Porzio G, Valle A, Aielli F, Casuccio A. Palliative sedation in patients with advanced cancer followed at home: a prospective study. J Pain Symptom Manage 2014; 47:860-6. [PMID: 24099896 DOI: 10.1016/j.jpainsymman.2013.06.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/05/2013] [Accepted: 06/16/2013] [Indexed: 10/26/2022]
Abstract
CONTEXT Home care programs in Italy. OBJECTIVES The aim of this study was to assess a protocol for palliative sedation (PS) performed at home. METHODS A total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam. RESULTS A total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P=0.012). The principal reasons to start PS were agitated delirium (n=20) and dyspnea (n=4). Mean duration of PS was 42.2±30.4 hours, and the mean doses of midazolam were 23-58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively. CONCLUSION This protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies.
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Affiliation(s)
- Sebastiano Mercadante
- Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy; Palliative Medicine, Department of Anesthesia & Intensive Care, University of Palermo, Palermo, Italy.
| | | | | | | | - Alessandra Casuccio
- Department of Sciences for Health Promotion "G. D'Alessandro"-Hygiene Section, University of Palermo, Palermo, Italy
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Lokker ME, van Zuylen L, van der Rijt CCD, van der Heide A. Prevalence, impact, and treatment of death rattle: a systematic review. J Pain Symptom Manage 2014; 47:105-22. [PMID: 23790419 DOI: 10.1016/j.jpainsymman.2013.03.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 03/03/2013] [Accepted: 03/19/2013] [Indexed: 11/28/2022]
Abstract
CONTEXT Death rattle, or respiratory tract secretion in the dying patient, is a common and potentially distressing symptom in dying patients. Health care professionals often struggle with this symptom because of the uncertainty about management. OBJECTIVES To give an overview of the current evidence on the prevalence of death rattle in dying patients, its impact on patients, relatives, and professional caregivers, and the effectiveness of interventions. METHODS We systematically searched the databases PubMed, Embase, CINAHL, PsychINFO, and Web of Science. English-language articles containing original data on the prevalence or impact of death rattle or on the effects of interventions were included. RESULTS We identified 39 articles, of which 29 reported on the prevalence of death rattle, eight on its impact, and 11 on the effectiveness of interventions. There is a wide variation in reported prevalence rates (12%-92%; weighted mean, 35%). Death rattle leads to distress in both relatives and professional caregivers, but its impact on patients is unclear. Different medication regimens have been studied, that is, scopolamine, glycopyrronium, hyoscine butylbromide, atropine, and/or octreotide. Only one study used a placebo group. There is no evidence that the use of any antimuscarinic drug is superior to no treatment. CONCLUSION Death rattle is a rather common symptom in dying patients, but it is doubtful if patients suffer from this symptom. Current literature does not support the standard use of antimuscarinic drugs in the treatment of death rattle.
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Affiliation(s)
- Martine E Lokker
- Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands; Department of Medical Oncology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands.
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Centre, Rotterdam, The Netherlands
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Mercadamte S. Death rattle: critical review and research agenda. Support Care Cancer 2013; 22:571-5. [PMID: 24253734 DOI: 10.1007/s00520-013-2047-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
Abstract
The aim of this critical review was to assess the literature regarding the treatment of death rattle at the end of life to provide an update information regarding this difficult issue. To provide suggestions for future research agenda, the approach was analytic and based on clinical considerations, rather than on raw evidence only. Both published and unpublished reports from an extensive search of electronic databases. Any randomized-controlled trial or clinical reports with a significant number of patients was considered. Eleven reports fulfilled the inclusion criteria in this systematic review. Four controlled studies, four comparative audits, and three clinical reports with a significant number of patients were selected. Despite anticholinergic or antimuscarinic medications are the drugs of choice in practice, there is a lack of supporting evidence for the use of anticholinergics to treat death rattle. Regardless of the methodological limitations of existing studies, an a priori observation was missed. Most studies were performed with the intent to treat rather than to prevent death rattle. However, from a pharmacological perspective, anticholinergic agents are unable to reduce the secretions once they are formed, but may just limit a further production. In conclusion, studies on the use of antisecretive agents provided only minor evidence of efficacy, ultimately raising questions about the routine inclusion of anticholinergic treatment in end of life pathways for the treatment of death rattle. However, this observation could be confuted by the use of these same drugs used earlier in a prophylactic perspective, in the context of a comprehensive management of the dying patients.
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Affiliation(s)
- Sebastiano Mercadamte
- Anesthesia & intensive Care & Pain Relief and Supportive Care, La Maddalena Cancer Center, Via San Lorenzo 312, 90146, Palermo, Italy,
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Chih AH, Lee LT, Cheng SY, Yao CA, Hu WY, Chen CY, Chiu TY. Is It Appropriate To Withdraw Antibiotics in Terminal Patients with Cancer with Infection? J Palliat Med 2013; 16:1417-22. [DOI: 10.1089/jpm.2012.0634] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- An-Hsuan Chih
- Health Center, Office of Student Affairs, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Long-Teng Lee
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Ching-Yu Chen
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
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Campbell ML, Yarandi HN. Death Rattle Is Not Associated with Patient Respiratory Distress: Is Pharmacologic Treatment Indicated? J Palliat Med 2013; 16:1255-9. [DOI: 10.1089/jpm.2013.0122] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Noisy breathing or death rattle is a common clinical sign in the final days of life. When it occurs, the level of consciousness is usually low and it is generally assumed that patients are not distressed by it. Despite the assumption that patients are not distressed, death rattle is usually actively treated in palliative care settings through a combination of pharmacological and non-pharmacological measures. Anti-cholinergic or anti-muscarinic medications are the drugs of choice in practice, even in the absence of patient distress, despite there being no conclusive evidence to suggest that any drug is superior to placebo. In addition, a recent Cochrane review suggested that there is a lack of supporting evidence for the use of anti-cholinergics to treat death rattle (Wee and Hillier, 2010). The choice of drug is based on the various properties of the drug and the desired effects. However, treatment is focused on alleviating the perceived distress of family members rather than aimed specifically at benefiting the patient. Moreover, anti-cholinergic drugs can result in unpleasant side-effects such as urinary retention and dry mouth for patients who are probably unable to report symptoms. Recent research calls for prescribers to consider carefully why they are treating death rattle. Moreover, families need to be reassured and have it explained to them that it is unlikely that the patient is distressed and why this is the case.
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Heisler M, Hamilton G, Abbott A, Chengalaram A, Koceja T, Gerkin R. Randomized double-blind trial of sublingual atropine vs. placebo for the management of death rattle. J Pain Symptom Manage 2013; 45:14-22. [PMID: 22795904 DOI: 10.1016/j.jpainsymman.2012.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/30/2011] [Accepted: 01/19/2012] [Indexed: 10/28/2022]
Abstract
CONTEXT Noisy breathing because of respiratory tract secretions (RTS), often referred to as "death rattle," occurs in up to half of all dying patients. Despite a lack of evidence showing benefit compared with placebo, antimuscarinic medications have been used in an attempt to decrease noise associated with RTS and to decrease family distress. OBJECTIVES The goal of this study was to compare the efficacy of the antimuscarinic medication atropine with that of placebo in reducing noise associated with death rattle. METHODS Terminally ill adult hospice inpatients who developed noisy breathing as a result of RTS were randomized to double-blind treatment with atropine or placebo. Study drug was given as a single sublingual dose. Noise from breathing was monitored at baseline and at two and four hours. RESULTS One hundred thirty-seven participants were randomized to atropine or placebo. Reduction in noise score from baseline to two hours after dose occurred in 37.8% and 41.3% of subjects treated with atropine and placebo, respectively (P=0.73). Noise score reduction at four hours occurred in 39.7% and 51.7% of subjects treated with atropine and placebo, respectively (P=0.21). Differences between groups were not significant at either time point. Atropine was well tolerated. Heart rate increased slightly in both groups (+1.1/minute for atropine and +3.1/minute for placebo) but not significantly. CONCLUSION Sublingual atropine given as a single dose was not more effective than placebo in reducing the noise associated with death rattle.
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Affiliation(s)
- Mark Heisler
- Hospice of the Valley, Phoenix, Arizona 85014, USA.
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Protus BM, Grauer PA, Kimbrel JM. Evaluation of Atropine 1% Ophthalmic Solution Administered Sublingually for the Management of Terminal Respiratory Secretions. Am J Hosp Palliat Care 2012; 30:388-92. [DOI: 10.1177/1049909112453641] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Terminal respiratory secretions (TRS) or “death rattle” is a common symptom in the dying patient. Current practice for the prevention and treatment of TRS involves the use of oral, sublingual, transdermal, or parenteral anticholinergic medications. A retrospective chart review of patients admitted to a hospice inpatient unit for terminal care and treated with sublingual atropine 1% ophthalmic drops for TRS was conducted. A total of 19 of 22 patients treated with atropine had documented reduction or resolution of TRS. This study suggests that atropine 1% ophthalmic drops administered sublingually are a reasonable option for the management of TRS. Problematic cardiac or central nervous system symptoms were not found in the present study. Results should aid hospice programs who are seeking guidance on the management of TRS with atropine 1% ophthalmic drops.
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Affiliation(s)
- Bridget McCrate Protus
- HospiScript Services, Dublin, OH, USA
- The Ohio State University, College of Pharmacy, Columbus, OH, USA
| | - Phyllis A. Grauer
- HospiScript Services, Dublin, OH, USA
- The Ohio State University, College of Pharmacy, Columbus, OH, USA
| | - Jason M. Kimbrel
- HospiScript Services, Dublin, OH, USA
- Ohio Northern University, College of Pharmacy, Ada, OH, USA
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Sheehan C, Clark K, Lam L, Chye R. A Retrospective Analysis of Primary Diagnosis, Comorbidities, Anticholinergic Load, and Other Factors on Treatment for Noisy Respiratory Secretions at the End of Life. J Palliat Med 2011; 14:1211-6. [DOI: 10.1089/jpm.2011.0191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Caitlin Sheehan
- The Cunningham Centre for Palliative Care, Darlinghurst, New South Wales, Australia
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Hospital, Newcastle, New South Wales, Australia
- Academic Department of Palliative Care, University of Newcastle, Newcastle, New South Wales, Australia
| | - Lawrence Lam
- Sydney School of Medicine, University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Palliative Care Services, Darlinghurst, New South Wales, Australia
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Alvarez A, Walsh D. Symptom control in advanced cancer: twenty principles. Am J Hosp Palliat Care 2011; 28:203-7. [PMID: 21398267 DOI: 10.1177/1049909111400725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In Palliative Medicine, symptom management is a clinical priority and one of the key skill sets of the palliative specialist. Symptom control principles have been derived from clinical practice in cancer pain management. They can also be applied to other cancer symptoms, and systematic application will help improve quality of life (QOL). They require a diagnosis of the underlying etiology, individualization of symptom therapy, a systematic approach to management, and therapeutic clarity and simplicity. There are 20 principles that have been identified as helpful to guide the clinical practice of symptom control in advanced cancer.
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Affiliation(s)
- Adriana Alvarez
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland, OH, USA
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Abstract
Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.
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Affiliation(s)
- Roschelle A Heuberger
- Department of Human Environmental Studies, Central Michigan University, Mt. Pleasant, Michigan 48859, USA.
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Mercadante S, Villari P, Ferrera P. Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents. J Pain Symptom Manage 2011; 41:637-9. [PMID: 21131169 DOI: 10.1016/j.jpainsymman.2010.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 06/04/2010] [Accepted: 06/06/2010] [Indexed: 11/24/2022]
Abstract
Anticholinergic drugs, including atropine, hyoscine butylbromide, and scopolamine, have been shown to be equally effective in the treatment of death rattle. However, anticholinergic drugs may only be effective in reducing the production of further secretions, rather than eliminating the existing ones. A case is described in which a preventive procedure was undertaken to carefully eliminate secretions before starting anticholinergic drugs. Airway aspiration under light anesthesia removed secretions before starting anticholinergic drugs. Low doses of propofol were given intravenously to make a laryngoscopy feasible, allowing the complete aspiration of large amounts of tracheal secretions. No death rattle was perceived until death. Relatives were satisfied with the treatment and the peaceful death. Antisecretory agents may only prevent further accumulation of fluids along the airways and in the pharynx. The use of these drugs, supplemented by this aspiration procedure in carefully selected patients, may help eliminate death rattle in patients with advanced illness who are unable to cough or swallow. Explanation and reassurance to relieve fears and concerns regarding a procedure aimed to improve the quality of end-of-life care are of paramount importance, and active collaboration in decision making facilitates a timely intervention. This preliminary experience may help further research on the best treatment at the end of life.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit & Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy.
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LeGrand SB, Walsh D. Comfort measures: practical care of the dying cancer patient. Am J Hosp Palliat Care 2010; 27:488-93. [PMID: 20801921 DOI: 10.1177/1049909110380200] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Most patients with advanced malignancy will die of their disease. Care of the dying is therefore a fundamental skill for the oncologist. Although protocols exist in other countries, there is no established protocol in the United States. We present a protocol for management of the dying that is clinically useful and review the existing evidence-base.
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Affiliation(s)
- Susan B LeGrand
- The Harry R. Horvitz Center for Palliative Medicine, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, USA.
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Vazquez R, Gheorghe C, Ramos F, Dadu R, Amoateng-Adjepong Y, Manthous CA. Gurgling breath sounds may predict hospital-acquired pneumonia. Chest 2010; 138:284-8. [PMID: 20348197 DOI: 10.1378/chest.09-2713] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To determine whether gurgling sounds heard during speech or quiet breathing, with or without a stethoscope over the glottis, predict hospital-acquired pneumonia (HAP). METHODS All patients admitted to the respiratory or general medicine ward of a 350-bed community teaching hospital were eligible. Patients were examined each day, and those who had upper airway gurgling, heard with or without the stethoscope, during breathing or speech at any point during admission were noted. Assuming an overall incidence of HAP (>48 h after admission) of 5% to 10% and estimated incidence of 30% to 50% in patients with gurgle, 20 patients with gurgle and 60 patients without gurgle, matched on the same day and ward of admission, were included in the study. Demographic, physiologic, and outcome variables were compared using univariate and multivariate techniques to ascertain whether gurgling is independently associated with HAP, rate of transfer to ICU, and inhospital mortality. RESULTS Twenty patients with gurgle were compared with 60 patients without gurgle. Patients with gurgle were older (78.5 vs 65.2 y; P < .001), more likely to reside in nursing homes (75% vs 6%; P < .001), and were more likely to have dementia (70% vs 13%; P < .001). In multivariate analysis, dementia (odds ratio [OR] = 23.4; 95% CI, 4.2-131.9) and recent (within 24 h) treatment with opiates (OR = 14.7; 95% CI, 2.2-97.5) emerged as the only statistically significant independent predictors of gurgling. HAP occurred in 55% of patients with gurgle compared with 1.7% of patients without gurgle (P < .001), and 50% of patients with vs 3.3% of patients without gurgle required transfer to ICU (P < .001). After adjustment for age, Charlson score, dementia, opiate administration, and stroke, gurgling emerged as the sole independent predictor of HAP (OR = 140.1; 95% CI, 5.6-3,529.4) and ICU transfer (OR = 35.1; 95% CI, 4.1-303.7). Gurgling did not predict mortality; the Charlson comorbidity index was the only significant predictor of inhospital death. CONCLUSIONS Gurgling sounds heard during quiet breathing or speech are independently associated with HAP.
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Affiliation(s)
- Rodrigo Vazquez
- Bridgeport Hospital and Yale University School of Medicine, 267 Grant St, Bridgeport, CT 06610, USA
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Clark K, Currow DC, Agar M, Fazekas BS, Abernethy AP. A Pilot Phase II Randomized, Cross-Over, Double-Blinded, Controlled Efficacy Study of Octreotide versus Hyoscine Hydrobromide for Control of Noisy Breathing at the End-of-Life. J Pain Palliat Care Pharmacother 2009; 22:131-8. [DOI: 10.1080/15360280801992058] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Wildiers H, Dhaenekint C, Demeulenaere P, Clement PMJ, Desmet M, Van Nuffelen R, Gielen J, Van Droogenbroeck E, Geurs F, Lobelle JP, Menten J. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage 2009; 38:124-33. [PMID: 19361952 DOI: 10.1016/j.jpainsymman.2008.07.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2008] [Revised: 07/21/2008] [Accepted: 08/08/2008] [Indexed: 11/18/2022]
Abstract
Death rattle is a frequent symptom (25%-50%) in the terminal stage of life, but there is neither standardized treatment nor prospective investigation performed on the effectiveness of anticholinergic drugs. The aim of the present study was to investigate the effectiveness of three different anticholinergic drugs in the treatment of death rattle in the terminal stage of life. Terminal patients who developed death rattle were randomly assigned 0.5mg atropine, 20mg hyoscine butylbromide, or 0.25mg scopolamine. Each treatment was initiated with a subcutaneous bolus, which was followed by continuous administration of the same drug. The intensity of death rattle and side effects were prospectively scored at different time points. Three hundred and thirty-three eligible patients were randomized to atropine, hyoscine butylbromide, or scopolamine after informed consent from the patient or the appointed representative. For the three drugs, death rattle decreased to a nondisturbing intensity or disappeared after one hour in 42%, 42%, and 37% of cases, respectively (P=0.72). Further, effectiveness improved over time without significant differences among the treatment groups (effectiveness at 24 hours was 76%, 60%, and 68%, respectively). In an analysis on the three groups together, treatment was more effective when started at a lower initial rattle intensity; median survival after start of therapy was 23.9 hours. These data suggest that there are no significant differences in effectiveness or survival time among atropine, hyoscine butylbromide, and scopolamine in the treatment of death rattle.
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Affiliation(s)
- Hans Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium.
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Kintzel PE, Chase SL, Thomas W, Vancamp DM, Clements EA. Anticholinergic medications for managing noisy respirations in adult hospice patients. Am J Health Syst Pharm 2009; 66:458-64. [PMID: 19233993 DOI: 10.2146/ajhp080194] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Anticholinergic medications for reducing noisy respirations in adult hospice patients are evaluated. SUMMARY Anticholinergic medications used to reduce noisy respirations from retained secretions in terminal patients include atropine, glycopyrrolate, scopolamine, and scopolamine derivatives. Pharmaceutical anticholinergic treatment of retained secretions in hospice patients was evaluated in six studies, three of which compared the efficacy of glycopyrrolate to scopolamine in actively dying patients. Subcutaneous glycopyrrolate, scopolamine hydrobromide, and scopolamine butylbromide were similar in their ability to reduce noisy respirations overall and lower and the level of distress exhibited by family members and visitors. Two of the six studies compared the efficacy of medication therapy after institutional formulary changes from scopolamine to glycopyrrolate. The same dosages of subcutaneous glycopyrrolate and scopolamine, which delivered an initial bolus followed by continuous infusion, were reported in each study. Both studies concluded that there was equivalent efficacy between the two products. One study reported a more rapid response in patients treated with glycopyrrolate. In comparison, the last study reported more rapid responses in patients who received scopolamine compared with patients who received glycopyrrolate. Retrospective reports described symptom improvement with parenteral scopolamine in most patients. CONCLUSION Parenteral and transdermal anticholinergic medications are useful for the reduction of noisy respirations in hospitalized hospice patients. Difficult administration makes oral and sublingual products less desirable for use in this population.
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Kim JH, Choi YS. The Last Hours of Living: Practical Advice for Clinicians. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2009. [DOI: 10.5124/jkma.2009.52.7.697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jung Hyun Kim
- Department of Family Medicine, Cheongju Hana General Hospital, Korea.
| | - Youn Seon Choi
- Department of Family Medicine, Korea University College of Medicine, Korea.
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Wilkins D. Understanding Changes in Breathing at the End of Life. J Palliat Med 2008; 11:1056. [DOI: 10.1089/jpm.2008.9856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912-27. [PMID: 18390964 DOI: 10.1164/rccm.200605-587st] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Abstract
Despite advances in cancer survival rates, end of life care remains a vital aspect of cancer management. The use of integrated care pathways can facilitate effective care of dying patients in a generalist setting. However, it remains important that staff are able to recognise the onset of the dying process, not only in order to make symptom control provision, but also that appropriate communication can occur with patients and those close to them. This allows the exercise of choice over place and style of care. The key symptoms at the end of life are restlessness, agitation, breathlessness, pain and noisy respiration from retained airway secretions. Ethical tensions arise from the assumptions that the use of opioids and sedatives hastens dying, but this is contradicted by available evidence.
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Affiliation(s)
- Nigel Sykes
- Palliative Medicine, St. Christopher's Hospice, Lawrie Park Road, London, United Kingdom.
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