Dyspnea | Identify cause
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Pneumonia is the most frequent cause; sometimes pulmonary edema -
Antibiotics might improve comfort (reduce secretions) but prolong dying. Discuss goals of care. If goal of care is comfort but no life prolongation, then “no antibiotics” is appropriate and necessitates good symptom management
Use opioids, as they are the most effective treatment
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Start with either 0.5 mg of hydromorphone SC every 4 h as needed or 2–2.5 mg of morphine SC every 4 h in opioid-naive patients -
If dyspnea is persistent, give doses every 4 h with breakthrough doses (10% of total daily opioid dose given every 1 h)
Use 20–40 mg of furosemide (SC or IV) if there is evidence of fluid overload Use oxygen
If dyspnea remains severe, prescribe
Prescribe nonpharmacologic therapy
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Terminal rales (“death rattles”) | Reposition the patient, as this is often the best strategy
Start pharmacologic treatment
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0.2–0.8 mg of scopolamine* SC every 4–6 h as needed (maximum dose is 0.8 mg SC every 2 h) -
Scopolamine might be more effective if given on a regular basis -
0.2 to 0.4 mg of glycopyrrolate SC every 4 h might be preferred (less sedative) -
20–40 mg of furosemide SC might help if there is fluid overload
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Pain | Prescribe opioid (oral or SC administration)
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Hydromorphone might be preferable because of fewer active metabolites, diminishing risk of opioid toxicity -
Start opioid slowly: 0.25-0.5 mg of hydromorphone every 4 h (can be given as needed; however, when the patient cannot communicate, low-dose regular medication is often preferable); or 1–2.5 mg of morphine SC every 4 h (second choice) -
After 24 h, calculate the daily dose needed and give regularly in divided doses with breakthrough doses (half of regular dose) every 1 h -
Increase regular dosage if > 3 breakthrough doses daily
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Agitation | Consider treatable causes of pain (eg, full bladder, fecaloma, dry mouth) Consider the following:
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Often irreversible (might be due to opioid toxicity. Reduce morphine dose or change to hydromorphone, which has fewer active metabolites) -
Antipsychotics are normally the first choice in delirium (eg, 2.5–5 mg of methotrimeprazine every 6 h as needed), but if agitation is mild to moderate in an actively dying patient, benzodiazepines given regularly (0.5–1 mg of lorazepam SC every 4 h regularly for palliative sedation) might be more useful than antipsychotics -
If benzodiazepines are ineffective or cause paradoxical excitation, change to 12.5–50 mg of methotrimeprazine over a 24-h period in divided doses every 4–6 h, or 0.5–2 mg of haloperidol SC every 30 min until agitation is controlled, then give regularly every 4–6 h
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Myoclonus (frequent side effect of morphine) | Change morphine to hydromorphone and add 0.5 mg of lorazepam every 4 h as needed or regularly |