End of Life

• Most medications targeting neuropathic pain are not available as injectables when subcutaneous route needed (e.g. gabapentin). A switch to opioid medication or titration of existing opioid doses will likely be necessary
• Given the focus on comfort, CNS side effects are often not as critical for patients. Good discussions are important. Faster titration of medications may result in more CNS depressant effects, which may be aligned with patient goals
• Patients usually require subcutaneous medications or alternative routes of administration of analgesics at the end of life when they lose the ability to swallow
• A history of substance use may affect the dosing of medications required at the end-of-life and may make the patient and family more reluctant to use opioids. Specialist consultation may be required

Consider non-pharmacological management in all patients where breathlessness has a significant impact on patient’s quality of life or function

• At End of life, as the patient’s condition deteriorates, opioid titration will likely need to be escalated for dyspnea
• Consider Palliative Care consultation as required

• As a patient’s condition deteriorates, sodium and fluid restrictions should be discontinued. Similarly, consider discontinuing hypodermoclysis when a patient has days-to-hours to live

Upper airway congestion is unlikely to cause distress to patients, who are usually unresponsive at this point. However, it may be a source of distress to family members at the bedside

• Discuss with family members about the cause of the upper respiratory secretions
• It is not indicative of any choking or drowning risk
• Non-pharmacological approaches are important
  • Repositioning of the patient, reassessment of fluid volumes, and possibly gentle suctioning can be considered
• Antimuscarinic agents can help to reduce this distressing symptom, though emerging evidence suggests the timing of their initiation may impact effectiveness
  • When needed, it is best to begin them early – prophylactically
  • Choice of antimuscarinic agent often depends on local availability and patterns of practice, but those that cross the blood-brain barrier will be more likely to increase sedation which may be pertinent in the clinical context
  • These medications are often included in the end-of-life care pathways available at many institutions (and in the ‘C2’ order set in Connect Care)

• ​​​​​​Patients continue to produce stool until the last hours of life. If no bowel movement, stimulant suppositories may be required every 3 days to prevent abdominal discomfort
• As a patient’s condition deteriorates, certain pharmacological or non-pharmacological interventions will become less realistic; if the patient has hours to short days to live, consider discontinuing bowel care if there are no obvious symptoms arising from constipation

• As a patient’s condition deteriorates, certain non-pharmacological interventions will become less realistic (e.g. exercise). Energy conservation and restoration will become of utmost importance
• Ensure that appropriate supports are in place to assist with activities of daily living and that nursing care is available as needed
• Drowsiness may increase as the end of life approaches due to disease progression (and/or medications). Some patients and families may even prefer increased sleepiness if the patient remains comfortable

Benzodiazepines

• Benzodiazepines are not a first line treatment for Restless Legs Syndrome but there is some limited evidence for their use. Benzodiazepines can carry significant risks including an increased risk of falls/fractures and decreased cognition. If the patient is experiencing refractory Restless Legs Syndrome causing significant sleep disturbance, or if benzodiazepines may potentially treat concurrent symptoms (e.g. anxiety), they could be considered. They may also be the only option for a patient who is no longer able to swallow
• Prescribers could consider initiating midazolam 1 mg subcutaneously q4h PRN
• Some drugs commonly prescribed at end of life, such as haloperidol and opioids, may potentially contribute to Restless Legs Syndrome

• ​​​​​​​Evaluate potential etiologies and discuss with patient/alternate decision maker. The likelihood of being able to determine a cause of the delirium becomes much less as a patient approaches the end of life
• For severe agitated delirium at the end of life and when goals are comfort focused, palliative sedation can be considered (e.g. continuous midazolam infusion). A Palliative Care specialist consultation is highly recommended for this

• At End of life, as the patient’s condition deteriorates, anorexia will worsen and it will not be amenable to therapy (including enteral/parenteral nutrition)
• Discussions around eating for pleasure may help patients to be able to balance adverse effects versus benefits at this stage
• If anorexia or conversations around the utility of nutritional therapy at end of life are of particular distress for the patient, family or team, a consultation from Palliative Care should be obtained

• As the patient’s condition deteriorates, muscle cramping may worsen and not be amenable to the recommended therapies
• If muscle cramps are causing significant pain, pain medication may be required
• Discuss with the patient and family that pharmacological therapy may increase drowsiness
• Consider Palliative Care consultation for refractory symptoms