TERMINAL PHASE

Most patients become unconscious only for the last few hours of life, although sometimes (especially with primary brain tumors) the period of unconsciousness can last for several days.

I. Drugs – The commonly used drugs in the terminal phase are:

  • Morphine

  • Chlorpromazine or methotrimeprazine

  • Scopolamine

  • Diazepam

A continuous subcutaneous infusion of drugs can be useful during the terminal phase, particularly at home. (see Subcutaneous Infusions)

If a patient has needed regular oral morphine he will continue to need it to remain pain-free  and peaceful. The equivalent IM dosage is half the oral dose (for example, a patient who was well-controlled on oral morphine 30mg every 4 hours will need IM morphine 15mg every 4 hours). The dose is increased if the patient seems restless due to increased pain. Occasionally two indomethacin 50mg suppositories are helpful if a patient with bone metastases gets pain on being turned.

Sedatives are quite often needed for agitation. Chlorpromazine 25mg to 50mg every 4 hours is usually adequate. Methotrimeprazine can be thought of as double-strength chlorpromazine and can be used in a continuous subcutaneous infusion 50mg to 100mg per 24 hours.

Scopolamine is a very useful drug for the terminal phase, being anti-cholinergic, drying up secretions, and reducing or abolishing respiratory bubbling (“the death rattle”). The usual dose is 0.4mg IM every 4 hours, or in a continuous subcutaneous infusion 0.8mg to 2.4mg per 24 hours. It is also very sedating

Diazepam enema 10mg is useful for terminal twitching or focal seizures which can be very distressing for relatives. Diazepam 10mg IM or IV is an alternative to the diazepam enema.

«  Warfarin should be stopped or reversed before the terminal phase. Otherwise terminal gastrointestinal bleeding can occur, and as sphincters relax in the hours before death altered blood comes out of the mouth, which is very distressing to relatives. (see Bleeding)

II. Care of the weak or semi-conscious— Retention of urine is common, especially if anti-cholinergic drugs are used. Examine regularly for bladder fullness (especially if the patient becomes restless) and insert an indwelling catheter if necessary. Turn the patient every 2 hours (unless turning causes the patient distress). Mouth care is needed every hour. Use “artificial tears” eye drops every 2 hours if eyes are getting dry or inflamed.

All procedures should be explained to the family, who may find staying with the patient easier if they are allowed to help.

III. Terminal agitation – Most patients dying of cancer enter a phase of unconsciousness before death but a few patients (about 1% to 2%) close to death become restless and agitated.  (It is obviously important to exclude discomfort from a full bladder.) They are usually mildly confused, but may be physically strong enough to be sitting up or even walking around. Their skin is often mottled due to poor peripheral circulation. They become increasingly distressed and dyspneic, and after several hours finally die.

It is difficult to understand why terminal agitation sometimes occurs. It may be due to hypoxia. (Some psychosocial professionals have noticed a correlation with denial and unfinished emotional business.) The patient becomes too mentally anguished for counseling help and needs urgent sedation. Without adequate sedation these patients have a most unpleasant and distressing death.

Powerful sedatives are needed for terminal agitation, and a combination of drugs should be given by IM injections or continuous subcutaneous infusion:

Drug IM Dose mg
per 4 hours

Continuous Subcutaneous Dose mg
per 24 hours

Morphine ˝ 4-hourly oral dose ˝ 24-hourly oral dose
Chlorpromazine 25mg to 75mg

Methotrimeprazine 25mg to 75mg 75mg to 150mg
Scopolamine 0.4mg 1.2mg to 2.4mg
Diazepam 10mg (IM or rectal)

Midazolam

20mg to 80mg

The dose of morphine should be roughly equi-analgesic to previous doses. If the patient has not previously needed opioid drugs, start with 5mg morphine IM every 4 hours, or 30mg morphine in a continuous subcutaneous infusion every 24 hours. (If the agitation appears to be due to pain, higher doses of morphine may be needed.)

It can be worrying for both doctors and nurses to sedate someone just before he dies. (“Did the injection I gave kill him?”) It is important to emphasize to carers that the above combination of drugs does not cause death (and indeed is occasionally used for severe insomnia quite safely). If the patient is sedated but does not die, the drugs can be reduced or stopped for a time, and the patient observed.

The level of sedation may be an important issue for the family and explanation is important. If the patient’s level of consciousness is allowed to lighten it is important to observe carefully, and not to allow him to become agitated and distressed.

«  This agitation is a terminal event, occurring only in the very last hours of life. It is NOT to be confused with the anguish and distress of many patients who are not yet dying and who need company and counseling and NOT sedation.

IV. Support of the family – Family members may find it difficult to concentrate properly or think clearly. They can need a surprising amount of guidance. (“You can sit down and hold his hand, like this.”) They will tend to take on the role that is expected of them, but may need guidance about what is appropriate. They benefit from comfort and touch (people under stress regress). They may not remember details of any information given them at this time. (see Support)

If other deaths have not been seen there may be misconceptions about what death will be like. As death approaches simple explanations are greatly appreciated.

Some common questions, asked or unasked, are:

  • Should we stay?

  • Will it be long?

  • Is he suffering?

  • Can he hear us?

  • What will happen?

  • Why has the breathing changed?

  • Why has the skin color changed?

  • Why is he still getting injections?

Dying patients can sometimes still hear from time to time even when they are semi-conscious. It can be helpful for the family to know this. Very lightly touching the eyelashes of the patient to see if the eyelid flickers can be a helpful guide to the level of consciousness.

Grief from previous deaths may be reawakened and it is a time when sympathetic listening is important. A common feeling is guilt at wishing the person would die, to end his suffering.

Keeping a vigil can become exhausting. It can be helpful to suggest a schedule of visitors, so that some keep watch while others rest. It is often difficult to judge how long a semi-conscious patient may live. The volume of the pulse is a guide – a full volume usually suggests that there are several more hours. The degree of difficulty in breathing, and the skin color (mottling or blueness suggesting shutdown of the peripheral circulation) are other guides.

Family members may be very distressed at the physical appearance of the body, and may feel unable to stay. They need permission not to be there.

After death allow time for the family to do what is important for them. Gently encourage them to see the body and say goodbye. Prayers at the time of death can be very comforting if appropriate for the family. Family members who have been very involved may want to help with laying out the body, and should be allowed to do so. The amount of time a person needs to spend with the body after death varies. Some people need to spend many hours in order to say goodbye. Others do not. Be flexible.

«  It is rarely helpful to transfer a dying patient from home to a hospital or in-patient hospice simply to die. (see Home Care)


The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.


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