Nonpharmacologic methods to utilize include avoidance of environmental stimuli, such as fatty, spicy, and salted foods; use of relaxation and distraction; and massage.22 Several medication classes have been utilized to treat nausea and vomiting: prokinetic agents (metoclopramide 10 mg three to four times a day, 30 minutes prior to meals and bedtime); dopamine receptor antagonists (haloperidol 1.5-5 mg two to three times a day); antihistaminic agents (promethazine 25 mg orally or IV every 4-6 hours, with a maximum dose of 100 mg/d); and selective 5 hydroxytryptamine-3 receptor antagonists (ondansetron 4-8 mg once or twice a day). Other agents that have been utilized include corticosteroids, benzodiazepines, octreotide, and cannabinoids.22
Procedures such as percutaneous endoscopic gastrostomy placement, nasogastric tube placement, and stenting may be necessary for patients who have advanced disease caused by a mechanical obstruction.22
Death Rattle
The death rattle occurs when secretions accumulate in the pharynx and/or airways when swallowing and cough mechanisms are no longer intact.24 This phenomenon occurs in 23% to 92% of dying patients.25 Generally, death occurs within 48 hours for about 75% of such patients.26 The noise that results from this process is usually more disturbing for those visiting the patients than to the patient themselves. Conservative measures to employ include placing patients on their sides to facilitate secretion drainage and to minimize upper airway sounds, gentle oral and pharyngeal suctioning, and limiting fluid input.11
One recent study reviewing the use of the anticholinergics atropine, scopolamine, and hyoscine demonstrated similar efficacy among the three drugs. Dosages used in this study included atropine 0.5 mg as a subcutaneous bolus, followed by 3 mg every 24 hours subcutaneously; scopolamine as a 0.25 mg subcutaneous bolus, followed by 1.5 mg every 24 hours IV or by subcutaneous infusion; and hyoscine 20 mg as a subcutaneous bolus followed by 60 mg every 24 hours IV or subcutaneous infusion. Glycopyrrolate is often used in the cognitively intact patient, as it does not cross the blood-brain barrier; however, supply concerns at the time of the study prevented a review of its efficiency.27 All of these medications are also available in oral and transdermal formulations.
Terminal Delirium
Delirium is a common complication for patients nearing the end of life, affecting as many as 88% of dying patients.28 It is characterized by an acute onset of cognitive impairment that may manifest as either a hyperactive or hypoactive state. Causes for terminal delirium are multifactorial. Initially, management should include prevention strategies, such as frequently orientating the patient, maintenance of day-night cycles, provision of adequate sleep, and minimization of sensory overload.11 When pharmacological therapy is required to improve quality of life, a neuroleptic medication, namely haloperidol, should be used initially. The addition of a benzodiazepine may help if the initial treatments are ineffective, or if sedation is desired.28
Summary
Emergency physicians have a unique opportunity to improve the quality of life for patients suffering serious illness, especially those who are actively dying. The management of pain and nonpain symptoms in patients who are at end of life, is a particularly important skill for every EP. If available, a consultation with a palliative care medicine consultant may improve both short- and long-term patient care.
Dr Galicia-Castillo is the Sue Faulkner Scribner professor of geriatrics at the Eastern Virginia Medical School Glennan Center for Geriatrics and Gerontology, and Medical Director for Palliative Care Medicine at Sentara Norfolk General Hospital. Dr Counselman is the distinguished professor and chairman of the department of emergency medicine at Eastern Virginia Medical School, Norfolk; and a physician at Emergency Physicians of Tidewater, Norfolk, Virginia. He is also the associate editor in chief of EMERGENCY MEDICINE editorial board.