Symptoms and Medicines
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Symptoms and Medicines

Symptoms commonly observed in the last days of life infographic - Terminal restlessness, anxiety, dyspnoea, nausea and vomiting, pain, respiratory secretionsThese pages are a resource to guide evidence-based practice in the care of older people in the last days of their life (terminal phase). On these pages many links direct you to the palliAGEDgp app. Once you have accepted the Terms and Conditions, you will have access to all app content. 

 

If you require other prescribing advice for more long-term palliative care, refer to the Therapeutic Guidelines (subscription required). 

Recognising or diagnosing dying is a vital and often the first step to ensuring that appropriate terminal care is in place.

Principles

Identification of the terminal phase requires the clinician to recognise when a person is actively dying. Signs of active dying include: bed-bound, unable to swallow, poor responsiveness with limited response to verbal or physical stimuli, reduced or no urine output, changes in breathing pattern and signs of peripheral shutdown. Clinicians need to consider the needs of the person and the inappropriateness of ongoing investigations. When a person has been diagnosed as dying, the goals of care have changed to the management of the terminal phase.

This diagnosis is the opportunity to support shared decision-making and to design care through conversations with the person their family and carers. It can help the avoidance of unnecessary and futile options of care, including hospital transfers and resuscitation. If a person dies peacefully without needless suffering, the family and carers have the best opportunity to see the death as a good death and have fewer difficulties as they grieve.

The identification that someone is in the terminal phase should trigger several considerations from the clinical team.

The clinical priorities of terminal care are:
  • talking to the person, the family and carers
  • managing symptoms
  • ensuring medicines are available for symptom management
  • withdrawing non-essential medicines
  • advising other health professionals involved in the person’s care.

For many healthcare providers, care for older people in the terminal phase will represent a small component of their workload. These pages recommend a suite of resources to help healthcare providers with issues about symptoms or medicines in older Australians entering the terminal phase.

All care of a person in the terminal phase should take into consideration the Advance Care Directive and End-of-Life discussions.

In the terminal phase, changes in physiology as the body shuts down and changes in the underlying illness contribute to some expected symptoms, including:

Follow the hyperlinks for information and resources relating to each symptom. Most of the included resources are freely available; those which require a subscription are noted as such.

Dysphagia is expected and often subcutaneous medicines are required. The subcutaneous route is used for ease of access, efficacy and safety. Anticipating the loss of swallowing is crucial in maintaining good symptom control.

Anticipatory prescribing facilitates prompt symptom control by initiating orders for appropriate medicines in anticipation of the symptoms arising. When the person requires medicines, they can be given without undue delay which may lead to unnecessary stress and escalation of care.

The multidisciplinary care team in the terminal phase will likely include the general practitioner, nurse practitioner, nursing staff, the care staff, the carer, and the community pharmacist, with involvement of the local palliative care team.

Prescribing guidance

palliAGEDgp smartphone application (available as an app or as online content)

Therapeutic Guidelines: Palliative Care (subscription required)

Useful information

palliAGEDgp smartphone application (available as an app or as online content)

CareSearch website

Remember

  • The terminal phase should be anticipated; planning for this requires proactive multidisciplinary collaborations.
  • Subcutaneous medicines are typically used to manage symptoms in the terminal phase, due to the incidence of dysphagia.
  • Enablers for a home death include advance care plan in place, good symptom management, access to a general practitioner and a full-time carer.
  • While dying in the community is often the person’s wish, this may not be feasible.
  • Dying at home or in residential aged care require different levels of planning.

 
This page was updated on 21 February 2019