1. The Terminal Phase
Rob Woodford
ST1

2. The terminal phase: What is it?
The period of inexorable and irreversible decline in functional status, prior to death
May be gradual or more sudden
Days/weeks
Fluctuating or unfolding gradually
May be after planned withdrawal of life sustaining intervention

3. What to look for Fatigue Loss of appetite Functional deterioration
Communication
Mobility
Social engagement
Progressive weight loss
Decreased level of consciousness
Mottled skin
Changes in breathing
Cheyne-Stokes breathing
Noisy respiratory secretions

4. Main aims Two main aims of end of life care:
Ensure best QOL for patient
Supporting families and being mindful of long term effects.

5. Discussing treatment options
No obligation to provide “futile” treatments
But there is an obligation to communicate
May know a good amount about potential treatments, but not why those options are not feasible.
Plan before a crisis
Discuss fears:
Choking/suffocating/drowning
Worsening pain
Many people in these situations worry about …
When you thing of the scary “What If” possibilities, what comes to mind?
You might be wondering about...

6. Ceilings of care In case of deterioration – what would we do
Where is the patient on their journey?
Where do they think they are?
Ask:
Whether they would want hospital transfer
Whether for CPR
PPC and PPD
If you became very unwell with a chest infection, would you want to go to hospital, if we thought it would help?
Would you like us to do our best for you here, and aim for a peaceful death without medical interference?

7. Poor oral intake calorie intake Impaired swallow common
Distinguish between
Focal problem related to neuro illness/hypercalcaemia
Part of profound generalised weakness in final days
No compelling evidence that increasing calorie intake improves comfort or outcomes.
Guide family to find other ways of supporting: basic care, just being present
calorie intake
There’s often no hunger or desire for food
The body cannot properly use the food it takes in
Strength
Energy
Functional status
Survival

8. Poor fluid intake
The body’s need for fluid reduces as they become weaker
Inconclusive evidence around thirst/dehydration/excess secretions
Dehydration may lead to impaired excretion and delirium
Artificial hydration may prolong dying process, aggravate oedema, require drips…
Hydration is likely to benefit in cases of
Hypercalcaemia
Reversible bowel obstruction
In absence of clear harm, hydration may help family navigate “path of least regret”
The deeply unconscious patient will not experience thirst

9. Poor fluid intake For Against
Maintenance of patient comfort (e.g. prevention of thirst, prevention of dry mouth)
Maintenance of renal perfusion
Prevention of accumulation of toxins and drugs
Prevention of delirium and opioid toxicity
Peripheral oedema
Cardiac failure
Respiratory secretions
Ketones and other byproducts of dehydration have analgesic and sedative effects

10. Management of pain NICE: SR morphine first line
Decreased conscious level:
Previous pain ongoing
Family and healthcare team assess comfort
Convert oral analgesia
Continuous diamorphine (or morphine) infusion via a syringe driver
PRN dose 1/6th driver dose
Consider leaving patch in situ

11. Management of dyspnoea
Non-pharmacological
Elevate head of bed
Fan for cool air
Oxygen may relieve dyspnoea
Pharmacological
Opioids mainly
Dose to comfort
If anxiety present, use benzodiazepines/levomepromazine
Oxygen – when to withdraw? No symptomatic benefit if unresponsive
Lets wean down the oxygen and see if he remains settled…

12. Management of agitation
Very common at end of life
Distressing for family
Many aetiologies
In final hours, don’t look for cause…
… But rule out hypoglycaemia and urinary retention.
If longer prognosis, consider investigating further or trying other treatments
Medication side-effect, brain tumour, infection

13. Management of agitation
Levomepromazine
PRN dose mg
In driver mg/24hrs
Haloperidol
Not as sedating as levomepromazine
From 0.5-3mg PRN
In driver 5-15mg/24hrs
Midazolam
PRN dose 2.5-5mg
In driver mg/24hrs
Lorazepam
PRN dose 0.5-1mg

14. Management of Nausea and vomiting
Treatment based on cause
Dysmotility
Metoclopramide
Biochemical
Haloperidol
Broad-acting
levomepromazine

15. The death rattle High prevalence Patient not usually responsive
Use an anticholinergic:
Hyoscine butylbromide 20-40mg s/c
Stat doses often work as well as infusion
Repositioning
Stop fluids

16. Risk of massive haemorrhage
Prepare healthcare staff
Education, clear plans
Discussions with patient and family.
If home death, will need clear open discussion, mostly with relative.
Medications and equipment ready
Needles/syringes, dark towels
Aggressive use of sedatives for rapid comfort/unawareness
E.g. midazolam 10mg IM/SC PRN
IM better than SC route

17. Summary Recognition important Individualised approach
Clinical needs
Patient and family views
Syringe-driver directive and anticipatory medications
Ensure family knows what to do following an expected death:
Call out of hours GP service to confirm the death
Family then organise an undertaker to take the body
Registered GP practice will normally complete the death certificate on the next working day

18. Guidelines