Anticholinergics in palliative medicine: an update

End-of-Life and Hospice Care in Neurologic Diseases

The care of a patient with neurologic disease at end-of-life requires expertise in addressing advance care planning, hospice, symptom management, and caregiver support. Neurologists caring for patients with advanced neurologic disease often identify changes in disease trajectory, functional status, or goals of care that prompt discussions of advance care planning and hospice. Patients nearing end-of-life may develop symptoms such as dyspnea, secretions, delirium, pain, and seizures. Neurologists may be the primary clinicians managing these symptoms, particularly in the hospitalized patient, though they may also lend their expertise to non-neurologists about expected disease trajectories and symptoms in advanced neurologic disease. This article aims to help neurologists guide patients and caregivers through the end-of-life process by focusing on general knowledge that can be applied across diseases as well as specific considerations in severe stroke and traumatic brain injury, amyotrophic lateral sclerosis, Parkinson's disease, and dementia.

Palliative Extubation: A Discussion of Practices and Considerations

Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.

Management of Physical Symptoms in Patients with Advanced Cancer During the Last Weeks and Days of Life

Patients with advanced cancer are faced with many devastating symptoms in the last weeks and days of life, such as pain, delirium, dyspnea, bronchial hypersecretions (death rattle), and intractable seizures. Symptom management in the last weeks of life can be particularly challenging because of the high prevalence of delirium complicating symptom assessment, high symptom expression secondary to psychosocial and spiritual factors, limited life-expectancy requiring special considerations for prognosis-based decision-making, and distressed caregivers. There is a paucity of research involving patients in the last weeks of life, contributing to substantial variations in clinical practice. In this narrative review, we shall review the existing literature and provide a practical approach to in-patient management of several of the most distressing physical symptoms in the last weeks to days of life.

Anticholinergic activity in the nervous system: Consequences for visuomotor function

Acetylcholine is present in the peripheral and central nervous system, where it is involved in a number of fundamental physiological and biochemical processes. In particular, interaction with muscarinic receptors can cause adverse effects such as dry mouth, drowsiness, mydriasis and cognitive dysfunction. Despite the knowledge that exists regarding these common side-effects, little is known about how anticholinergic medications influence central motor processes and fine motor control in healthy individuals. This paper reviews critical visuomotor processes that operate in healthy individuals, and how controlling these motor processes are influenced by medications that interfere with central cholinergic neurotransmission. An overview of receptor function and neurotransmitter interaction following the ingestion or administration of anticholinergics is provided, before exploring how visuomotor performance is affected by anticholinergic medications. In particular, this review will focus on the effects that anticholinergic medications have on fixation stability, saccadic eye movements, smooth pursuit eye movements, and general pupil dynamics.

End-of-Life Care of Patients With Amyotrophic Lateral Sclerosis and Other Nonmalignant Diseases

Background:

Palliative care services extend to meet the needs of patients with nonmalignant diseases.

Aim:

To explore the diagnoses, symptoms, and treatment of patients dying in hospice due to nonmalignant diseases, with special emphasis on amyotrophic lateral sclerosis (ALS).

Design:

A retrospective study based on a detailed analysis of patient records.

Setting/Participants:

All patients with nonmalignant diseases who died in Pirkanmaa Hospice during the period 2004 to 2013 were included.

Results:

Of the 67 patients studied, 48% had ALS, and the remaining had pulmonary (18%), cardiovascular (13%), neurologic (10%), and other (10%) diseases. Dyspnea, followed by pain and fatigue, was the most common symptom reported, increasing in frequency from admission to the last day of life (31% vs 48%; P < .05). Compared with ALS, patients with other diseases had more comorbidities (3.8% vs 1.4%, P < .001) and were more likely to have very short (≤3 days) final care periods (31% vs 9%; P < .05). During the last day of life, patients with ALS were more frequently unable to swallow (87% vs 31%, P < .001) and received significantly more antidepressants, antibiotics, and laxatives but less corticosteroids and oxygen compared to other patients. Noninvasive ventilation was used in 31% of all patients.

Conclusion:

Respiratory symptoms are important in the management of nonmalignant diseases in hospice. Especially, units taking care of ALS should be prepared to meet the special needs involved in ventilation support. In contrast to ALS, late referrals to hospice are common in patients with other nonmalignant diseases.

Death rattle: critical review and research agenda

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.