For those who take the drug, the physician’s writing a prescription is a necessary step in the process that leads to the patient’s death, but it is not the determinative or even the final step.Įuthanasia, on the other hand, generally means that the physician acts directly, for instance by giving a lethal injection, to end a patient’s life. The physician provides the means for death but it is the patient who must make the conscious decision to use the drug to effect death. Caution should be used in placing new venting gastrostomy tubes in the final days of life because of the high risk of procedural complications and a lack of quality evidence showing prolongation of life.Physician-Assisted Suicide generally refers to a practice in which the physician gives a patient a prescription for a lethal dose of medication, which the patient intends to use to end his/her life. 29 Some patients with malignant bowel obstruction have a prophylactic venting gastrostomy tube placed earlier in the disease process to release pressure upstream of the obstruction and prevent vomiting. 28 Octreotide (Sandostatin) has been used for the management of malignant bowel obstruction, but the data supporting its use are not robust. When malignant bowel obstruction is suspected in end-of-life care, medical management with an antiemetic (e.g., haloperidol), as well as corticosteroids and analgesics, is recommended. 27 Clinical symptoms of malignant bowel obstruction include nausea, vomiting, abdominal pain, and an inability to tolerate oral intake. Malignant bowel obstruction is common with pelvic and gastrointestinal cancers. Vomiting can occur because of mechanical bowel obstruction. Ondansetron (Zofran 4 to 8 mg orally or IV every 4 to 8 hours) Metoclopramide (Reglan 5 to 20 mg orally or IV every 6 hours)Ĭonsider in gastroparesis avoid in suspected malignant bowel obstruction Prochlorperazine (5 to 10 mg orally or IV every 6 to 8 hours)Ĭhlorpromazine (12.5 to 25 mg IV or 25 to 50 mg orally every 6 to 8 hours) Haloperidol (0.5 to 2 mg orally or IV every 4 to 8 hours) Marijuana (recommended only in states where legal for medical use)ĭexamethasone (2 to 8 mg orally or IV every 4 to 8 hours)Ĭonsider in suspected malignant bowel obstruction or with increased intracranial pressure Lorazepam (Ativan 0.5 to 2 mg orally or IV every 6 hours)ĭronabinol (Marinol 5 to 10 mg orally, rectally, or sublingually every 6 to 8 hours) May also help to decrease oral secretions Scopolamine (1 or 2 1.5-mg patches applied topically and changed every 72 hours) 12 Tachypnea, increased difficulty breathing, restlessness, and grunting are clinical signs of dyspnea, regardless of a patient's measured oxygen saturation. The Respiratory Distress Observation Scale ( ) is an eight-variable tool yielding a score of 0 (no dyspnea) to 16 (most dyspnea) based on observers' clinical assessments, and has been studied in the care of patients at the end of life. Measuring and quantifying dyspnea in patients with decreased responsiveness at the end of life can be challenging because most dyspnea scales require the patient to report symptoms. 8 – 11 Dyspnea can be caused by a number of different mechanisms, including aspiration pneumonitis or pneumonia, airway hyperreactivity, pulmonary edema, pleural effusions, and deconditioning. Effective symptom control in end-of-life care can allow patients to progress through the dying process in a safe, dignified, and comfortable manner.Īlthough dyspnea often occurs in patients with end-stage pulmonary and cardiac disease, it is also regularly observed in patients with cancer, cerebrovascular disease, or dementia. Anticholinergic medications can modestly help reduce these secretions. Providing anticipatory guidance helps families and caregivers normalize this symptom. Oropharyngeal secretions may lead to noisy breathing, sometimes referred to as a death rattle, which is common at the end of life. Preventive regimens to avoid constipation should include a stimulant laxative with a stool softener. Constipation may be caused by low oral intake or opiate use. Nausea and vomiting should be treated with medications targeting the etiology. When medications are required, haloperidol and risperidone are effective options for delirium. Delirium and agitation may be caused by reversible etiologies, which should be identified and treated when feasible. Opiates are the medication of choice for the control of pain and dyspnea, which are common symptoms in the dying process. As swallowing function diminishes, medications are typically administered sublingually, transdermally, or via rectal suppository. When possible, proactive regimens that prevent symptoms should be used, because it is generally easier to prevent than to treat an acute symptom. Physicians should be proficient at managing symptoms as patients progress through the dying process.
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