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The Terminal Phase
Rob Woodford
ST1
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
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
Main aims
 Two main aims of end of life
care:
 Ensure best QOL for patient
 Supporting families and being
mindful of long term effects.
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...
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?
Poor oral 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
Poor fluid intake
 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 body’s need for fluid
reduces as they become
weaker
The deeply unconscious
patient will not experience
thirst
Poor fluid intake
For
Against
• Maintenance of patient
comfort (e.g. prevention of
thirst, prevention of dry
mouth)
• Peripheral oedema
• Cardiac failure
• Respiratory secretions
• Maintenance of renal perfusion
• Prevention of accumulation of
toxins and drugs
• Prevention of delirium and
opioid toxicity
• Ketones and other byproducts
of dehydration have analgesic
and sedative effects
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
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…
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
Management of
agitation
 Levomepromazine
 PRN dose 6.25-12.5mg
 In driver 12.5-50mg/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 10-100mg/24hrs
 Lorazepam
 PRN dose 0.5-1mg
Management of
Nausea and vomiting
 Treatment based on cause
 Dysmotility
 Metoclopramide
 Biochemical
 Haloperidol
 Broad-acting
 levomepromazine
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
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
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
Guidelines
 http://wmpcg.co.uk/