discussion last time about prognosis was really interesting and just kind of talking through how in our different cultures and different institutions we approach those conversations. So the second half of the talk is just about some evidence-based management of symptoms at the end of life and I'll share my slides so that some of the links I have at the end are available because I've got some good resources for folks. So yeah, this is our prognostication from last time but I'll jump right in. So when we think about the dying process, you know, there are some symptoms that can herald that a patient is entering the active phase of dying and when it's recognized, you know, there's really no specific time that's attributed to active dying but it could be hours to up to two weeks and some of that really depends on when the caretaker or the practitioner recognizes that the patient has entered the dying phase. Some of the early symptoms of dying are, you know, patients will be more bed-bound, spending less and less time up and about. Family members may report that they are taking in less food and drink and are sleeping more, particularly during daylight hours. This sort of middle phase of the dying process, even fewer or even less time awake and if a person is having vital signs, this is when we start to notice some fluctuating, sometimes bradycardia, sometimes tachycardia, changes in breathing patterns and this is when patients may start to have an inability to manage their secretions, which I'll talk about in a little bit, which here in the United States is referred to as a death rattle. Finally, in the very late phases of the active dying phase when we're in the more hours realm, patients are not awake, fever is very common, apneas of increasing duration are seen and then modeling of the extremities, usually starting in the toes and the feet with coolness that's going to head up towards the knees and thighs is something that most people will notice in a dying patient. So I'm going to go just symptom by symptom. Fever, as I mentioned, is a common symptom at the end of life and it has many etiologies. You know, we often think of infection, but it's particularly in our cancer patients. Tumor burden is often the culprit. Some folks who have many chronic comorbidities, it could be medication induced if they're on lots of meds and then always clots can cause fevers and really management is supportive and the recommendation is to just try to consider if your patient seems uncomfortable. The problem is if a family knows that their loved one has a fever, it feels kind of hard not to treat that because throughout your life from when you have children, if you want to treat fevers, it feels like the right thing to do. So if you think your patient's uncomfortable or if family are really insistent that you treat a fever, Tylenol, acetaminophen or NSAIDs are your first line. There have been multiple studies which show that antibiotics are inconsistently useful at the end of life, particularly for fever. If a patient has an infection that's causing pain, then an antibiotic makes a lot of sense, but for just treatment, empiric treatment of a fever, antibiotics are not generally used. And then a good starting point is acetaminophen, 650 milligrams every four to six hours and suppositories, if they're available to you, are going to be really useful as patients are awake less and unable to take PO. And then as I'll mention in almost all of the slides to come, a medication review is always going to be important because especially at the end of life, you want to discontinue as many unnecessary medications as you possibly can. Agitation is another really common symptom at end of life. While we all hope to have a peaceful passing, it's pretty rare that a patient doesn't have at least some periods of agitation when they're close to end of life. Again, medication reconciliation is really important because there are many bad actors which can cause agitation. In our patients, particularly those who have metastatic liver disease and therefore liver dysfunction, metabolic derangements can be a big contributor to agitation and it's pretty hard to treat. Whereas opioids and other meds can cause agitation, pain can also cause agitation. And so it's kind of trying to decide, is it the medication or do I need more of this medication to help treat this symptom? And then there's often reversible causes that are easy to overlook, but really simple. And if your patient hasn't had a bowel movement in a week, maybe a disimpaction can help them at least treat some of what's underlying agitation. Urinary retention can be another one. If you need to use medications for agitation at the end of life, here we tend to reach for haloperidol first. It's a very old medication. We know it well. You can dose it pretty liberally and it's got the same bioavailability for oral and IV formulations. In the palliative care world, I think at least my teaching was to start with anywhere from a half a milligram to two milligrams and go up pretty liberally with dosing every 15 to 30 minutes. And the point is that you're trying to achieve rest for your patient and provide safety for both the patient and the provider. In general, we try to avoid benzodiazepines for agitation treatment at end of life. This can actually cause paradoxical worsening of agitation. If you're already using haloperidol and the person is just really, really hard to control, in combination and carefully, you can use benzodiazepines. You just usually using lorazepam, half a milligram IV or by mouth every two hours. You're not going to dose it nearly as frequently as you would haloperidol. And then remembering that if a person has end stage liver disease or liver metastasis, that lorazepam is actually a medication you'd rather avoid. Secretions, something that we talked about being one of the heralds of death and I think one that's very recognizable for family members. Secretions just come from decreased consciousness in your patient. And so they don't manage that saliva well and it's pooling in the oropharynx above the vocal cords. And it's really, it's just noisy breathing. The problem is it's deep enough that it can't be sufficiently suctioned. And if your patient's not awake enough to cough or is losing that reflex, then they're not going to clear it themselves. Again, it is distressing for families. It's one of the most common requests for treatment in like in the hospice house here. And I think it's a good time, it can be a good time to really start to prepare the family that death is more imminent. In the palliative care world, I was taught to quote about 48 hours till death when you start to notice this symptom. In one of the studies that I'm pretty sure I've cited for you at the end, they actually had a median time of death of 16 hours from onset of death rattle. So it's somewhere between 15 and 48 hours, but it is a pretty good sign that death is near. There's a lot of data around management of secretions because it's such a distressing symptom. And our largest meta-analysis in the Cochrane database actually showed that there was no pharmacologic intervention, which was better than placebo. Postural drainage is what we teach as the best thing to do. And so frequent turning with your nurses or teaching family members how to do so can be really helpful. Positioning with extra pillows is good. And again, there's many agents that exist and are used really frequently in the anesthesia world. But especially when you're at end of life, the side effect profile is really important to consider because they're all anticholinergics and they act centrally, they act peripherally, and they can be pretty bad actors when it comes to inducing agitation. So you don't want to take away secretions to induce agitation. If a medication is to be used, I was always taught to use hyosiamine. It's an orally available sublingual. If you can get it, it's actually less expensive than some of the others. And it has a short onset and fewer side effects. And then I've put your dosing here usually every four hours. Dyspnea is a very distressing symptom. At end of life, it's another one that's pretty common whether or not a lung pathology exists in your patient. It though has oftentimes even more reversible causes than some of our other symptoms. So it's really important to consider, is this patient still on IV fluids if they're in the hospital? Those should certainly be discontinued. Are they on TPN? Do they have a pleural effusion that I could either tap with a thoracentesis or place a pleurex strain? But looking for ways to reverse anything you can before reaching for meds is super important in dyspnea. And again, for this symptom, supportive care has some of the best evidence we have. Elevating the head of the bed is important. And there are actually several studies about fan use at end of life, including randomized trials, which have shown that a fan at the bedside may be even more helpful than supplemental oxygen. Oxygen is absolutely okay, and plenty of patients report that it's helpful. But for someone who's unconscious, a fan can be even more helpful than an oxygen tubing, which may end up causing agitation. If your patient's awake and interactive, teaching breathing techniques can also be helpful. And then finally, if medications are going to be used, low-dose opioids are the first-line treatment. Just remembering that if your patient is already on other opioids for pain, you want to be careful. That said, even someone who's been on chronic opioids for pain can get some benefit. And I was always taught to start with low-dose morphine, sublingual, and often found that patients did get some relief in their dyspnea by adding that, even if they were already on, say, like a long-acting oxycodone or something like that. And then pain is something that we all hope to avoid for ourselves and absolutely for our patients at the end of life. There's a lot of literature around inadequate management of pain at end of life, oftentimes because of worries about hastening the dying process. Again, looking for inciting factors is really important. Maybe the patient just needs to be repositioned. Maybe there's a bowel or bladder, something that can be fixed. But as your patient becomes less and less conscious, it's important to look for nonverbal signs of pain. And I've got them listed here. They're really, if you're thinking to look for them, they're pretty obvious, but it can also be easy to miss if you're not thinking to look. Medication for pain control at end of life is absolutely driven by prognosis. When someone's close to the end of life, there's really no ceiling on your opioids. You're not worried about addiction. But if someone's got weeks or months, you may want to think about trying to use some adjuvant medications, like acetaminophen and NSAIDs, to aid your opioids because they want to maintain more consciousness or want to be more interactive with their family. So the limitation for the adjunct meds that are non-narcotic is, you know, if your patient's less awake, these are harder to get in IV or sub-Q formulations. Tylenol is usually pretty available by a suppository, but it can be harder and harder to use adjuncts as a patient is unable to swallow or less conscious. New start opioids, it's important that they're begun on a continuous rate of an IV or subcutaneous infusion. And again, morphine is usually our first line, five to 10 milligrams by mouth, if that's possible, or one to four milligrams IV. And then remembering to use a bowel regimen in conjunction with your opioids. And then I just want to briefly touch on something in the palliative world that's considered really frequently, but not always taught in clinical medicine, in oncology, which is total pain. And it's this idea of, you know, it's a combination of physical, mental, emotional, spiritual, existential pain, all of which really contribute and affect your overall emotional, spiritual, existential pain, all of which really contribute and affect your ability to treat someone's physical pain. And oftentimes these are related to a patient's unfinished business in life, maybe guilt, maybe unresolved spiritual distress. And if they're awake and can talk to you, it's important to try to engage your patients on some of these themes because it can help you down the line, treat them. Maybe they need to see a family member. That's an important person they need to apologize to, or say something to. Maybe they need the chaplain to come see them, but you can often help yourself treat physical pain better by understanding a little bit more about the other types of pain your patient may be dealing with that isn't always something that we ask about in a history. And so in conclusion, you know, I think last time we talked about how prognostication is a tough conversation no matter what, but with some humility and the ability to ask questions and culturally understand where your patient's coming from, you can help them make good decisions. There are a series of signs and symptoms which herald the dying process, and the ability to recognize those is going to help you educate your patient and their families as they come closer to the end of their life. And then when treating symptoms in the dying patient, looking for reversible causes and doing a good medication reconciliation is going to be the most important first steps prior to reaching for anything pharmacologic, although it feels like the right thing to do is to just get some medicine in them to make them feel better. Taking a step back and really making sure you're thoughtful about what could be driving the symptom is really important. And then finally, just remembering that physical pain is best treated when the entire patient is considered. And then I hope that these can be some helpful resources for folks. This palliative performance scale is one that we use for all, like all levels of palliative care, even at the very end of life when people are in inpatient hospice. And it can be helpful so that you can kind of assess where your patient is. Fast Facts is something that's used frequently in palliative care. It's from the University of Wisconsin, and they literally are these really compact little like themed answers to questions like, you know, how do I treat agitation at end of life? And so this is a free website that you can go to, and it's wonderful. And then the pink book is a pain management and opioid conversion book that comes from the Dana-Farber and is a really wonderful resource if you're trying to dose opioids particularly and you're trying to move between different types and have any questions about how to do that. And then I have references for you. And I'll be happy to take questions if there are any or hear anybody else's experiences with any of those themes. Or they could email you, right?

evidence-based management

symptoms

end of life

prognosis

dying process