1. Common Symptoms at End of Life Stephanie Reynolds, MSN, NP, ACHPN Palliative Care, Jacobi Medical Center

2. Assess Patient looks uncomfortable: Patient looks uncomfortable: Pain? Pain? Anxiety? Anxiety? Dyspnea? Dyspnea? Make sure that you rule out: Make sure that you rule out: Discomfort because of hygiene needs, need for repositioning Discomfort because of hygiene needs, need for repositioning Constipation, urinary retention Constipation, urinary retention Thirst, dry mouth Thirst, dry mouth

3. Preventing Pain If the patient has a reason to have pain, they are likely in pain. If the patient has a reason to have pain, they are likely in pain. Avoid repeated subcut injections if possible – can be painful Avoid repeated subcut injections if possible – can be painful IV medication is best if pt is unable to swallow IV medication is best if pt is unable to swallow May need to consider continuous drip to provide steady level of pain medication in bloodstream May need to consider continuous drip to provide steady level of pain medication in bloodstream

4. Preventing Anxiety Why is this patient agitated? Why is this patient agitated? May be pain, dyspnea, constipation, hunger… May be pain, dyspnea, constipation, hunger… Avoid restraints Avoid restraints Order standing or prn medication for anxiety Order standing or prn medication for anxiety Avoid Ativan IM, if possible; give either IV or SL Avoid Ativan IM, if possible; give either IV or SL Chaplain? Chaplain?

5. Preventing Dyspnea Opioids very effective for dyspnea, but given at much lower doses than for pain Opioids very effective for dyspnea, but given at much lower doses than for pain i.e. morphine liquid 2-5 mg PO or via GT/NGT q 6 hrs standing i.e. morphine liquid 2-5 mg PO or via GT/NGT q 6 hrs standing Anxiolytics are also helpful Anxiolytics are also helpful Consider a fan at bedside (we have some!) Consider a fan at bedside (we have some!)

6. Other Symptoms “Death rattle” / excess secretions “Death rattle” / excess secretions Levsin 0.125 mg SL q 6 hrs around the clock Levsin 0.125 mg SL q 6 hrs around the clock Glycopyrrolate 0.1-0.2 mg IV q 8 hrs around the clock Glycopyrrolate 0.1-0.2 mg IV q 8 hrs around the clock Diminished blinking Diminished blinking Natural tears eye drops, 2 drops to both eyes q 6 hrs and prn Natural tears eye drops, 2 drops to both eyes q 6 hrs and prn Dry mouth Dry mouth Artificial saliva, 5 mL q 6 hrs – apply to oral swab for mouth care Artificial saliva, 5 mL q 6 hrs – apply to oral swab for mouth care Ice chips Ice chips