Herckleperckle
Member
11-20-2003
| Wednesday, August 24, 2005 - 5:32 am
Source: Palliative Care Perspectives Palliative Care Perspectives by James L. Hallenbeck I've included the following excerpt from the book noted above: Palliative Care Perspectives: Chapter 11: The Final 48 Hours: Symptoms of Active Dying Many people do fine during active dying. However, certain symptoms may arise that require attention. In a study of symptoms that occurred in 200 actively dying cancer patients, Lichter found the symptoms shown in the Table below.
Symptom Frequency | (in percent) | Noisy and moist breathing | 56 | Urinary incontinence | 32 | Urinary retention | 21 | Pain | 42 | Restlessness and agitation | 42 | Dyspnea (uncomfortable breathing) | 22 | Nausea and vomiting | 14 | Sweating | 14 | Jerking-twitching-plucking | 12 | Confusion | 8 | This study provides a useful checklist for symptoms to consider and some interesting food for thought. It is not surprising that incontinence was present in one-third of patients. The clinician may be surprised at the relatively high incidence of urinary retention. Clinicians may be fooled into thinking that lack of urine output reflects dehydration or renal failure. Palpatating the bladder and watching to see if the patient is distressed and reaches for the groin may provide clues to occult retention. Nausea tends to fade in the actively dying, which is probably related to decreased oral intake. The percentage of confused patients in this study seems remarkably low to me. The considerably higher percentage of restless and agitated patients suggests that altered states are not uncommon in actively dying patients. This begs the question of how one might distinguish "confusion" from "restlessness and agitation." Actively dying patients frequently develop irregular, or Cheyne-Stokes, respirations. Irregular breathing is rarely distressing to patients. Dry mouth persists far into the dying process and requires meticulous attention. Agitation or terminal distress can be very troublesome and often requires some degree of sedation. There is no evidence that such sedation (or treatment of pain with opioids) significantly hastens death in the last 48 hours, as Morita and colleagues found in a study correlating time of death with opioid and sedative doses over the last 48 hours. Pains certainly were not rare in the Litcher study. New pains were identified 29.5% of the time. However, no pains were judged as persistent or severe. The study was conducted on a hospice ward. This stands in sharp contrast to the SUPPORT study, in which 50% of dying patients in the hospitals studied were judged by relatives to have had 7 of 10 or greater pain in the last three days of life. In the Litcher study, 91% of patients were on opioids, and 91.5% of deaths were judged to be peaceful. This study is good news for those patients, families, and clinicians who want data regarding dying. Contrary to common fears, paroxysms of pain and great distress are uncommon at the very end. Most dying can be peaceful if we support it properly. Ellershaw and colleagues recently documented, using a standarized evaluation instrument, the Integrated Care Pathways (ICP) assessment tool, that 80% of the 168 patients followed had either good control of the three symptoms that were followed (pain, agitation, and respiratory secretions) or only one episode "out of control" in the last 48 hours when good palliative care was provided. "As death neared, there was a statistically significant increase in the number of patients whose pain was controlled." More of this chapter can be found at the link provided above.
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