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
– The commonly used drugs in the terminal phase are:
continuous subcutaneous infusion of drugs can be useful during
the terminal phase, particularly at home.
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
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
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.
procedures should be explained to the family, who may find
staying with the patient easier if they are allowed to help.
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.
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:
IM Dose mg
per 4 hours
Continuous Subcutaneous Dose mg
per 24 hours
4-hourly oral dose
24-hourly oral dose
25mg to 75mg
75mg to 150mg
1.2mg to 2.4mg
10mg (IM or rectal)
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.
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
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.
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.
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:
the breathing changed?
the skin color changed?
Why is he
still getting injections?
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.
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.
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.
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.
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
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.