Management of bleeding in the terminally ill patient

Clinically significant bleeding occurs in approximately 6%-10% of patients in the palliative-care setting. Bleeding can range from persistent and small in quantity (but enough to interfere with a patient's quality of life), to catastrophic bleeding that ultimately leads to the rapid demise of the patient. Uncontrolled bleeding can be very distressing for staff, patients and families. Advanced planning is necessary in all bleeding circumstances. This session will review the types of cancer associated with bleeding, as well as management options for these situations. Emphasis will be placed on aspects of communication with families.     

Management of bleeding in the terminally ill patient

Clinically significant bleeding occurs in approximately 6%-10% of patients in the palliative-care setting. Bleeding can range from persistent and small in quantity (but enough to interfere with a patient's quality of life), to catastrophic bleeding that ultimately leads to the rapid demise of the patient. Uncontrolled bleeding can be very distressing for staff, patients and families. Advanced planning is necessary in all bleeding circumstances. This session will review the types of cancer associated with bleeding, as well as management options for these situations. Emphasis will be placed on aspects of communication with families.     

Ethical decisions in the care of a patient terminally ill with metastatic cancer

A case of a patient with metastatic cancer raises the issues of patient refusal of treatment, euthanasia, and unintended side effects of therapy. For each management dilemma, there are relevant ethical and legal considerations, justifications, and conclusions. In addition, psychological and social influences on the decision process tend to limit deliberation.     

Delirium in the terminally ill

Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. The cause of delirium is usually multifactorial and often cannot be found or reversed in dying patients. Nonpharmacologic and pharmacologic interventions are effective in controlling the symptoms of delirium in terminally ill patients. Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.     

Clinical management of the terminally ill.

Physicians who provide primary care for the elderly are spending more time caring for terminally ill patients. Although curing these patients' illnesses is impossible, it is often possible to improve their quality of life and give them more control over their illness. Communication with the patient and family members, advance directives, and planning for death are important. Symptoms such as pain, dyspnea, and nausea can usually be controlled. Other health care professionals and hospice care when appropriate can also be helpful.     

Psychotropic drugs for terminally ill patients with respiratory disease

Utilization of psychotropic drugs including hypnotics, sedatives, and parenteral morphine for terminally ill patients with respiratory disease has not been reported precisely. To better understand these drugs for dying patients with respiratory disease, we focused on the last month of life of them. A chart review, which was focused on symptoms and managements, in the last month of life of 337 patients who died of respiratory disease between April 2000 and March 2005 were performed. Hypnotics were prescribed in 35.8% and 23.2% of patients with malignant and non-malignant disease, respectively. Sedatives such as haloperidol and midazolam were utilized in 34.4% of patients with malignant disease, and 30.4% of those with non-malignant disease. Sixty-seven percent of patients with malignant and 22.4% of those with non-malignant disease had parenteral morphine. In patients with malignant disease, three of the main reasons for administration of morphine were pain, dyspnea, or terminal restlessness. In all of the patients with non-malignant disease, however, parenteral morphine was prescribed for the treatment of dyspnea. Our results showed that psychotropic drugs and parenteral morphine are required in some of terminally ill patients with respiratory disease. Although careful individualization of medication is appropriate, guideline for the prescribing psychotropic drugs for these patients will be required.     

Dyspnea in terminally ill cancer patients

To determine the epidemiology of dyspnea in terminal cancer patients, we examined data from the National Hospice Study, which followed up patients during their last six weeks of life. The incidence of dyspnea in these patients was 70.2 percent, with prevalence rates generally exceeding 50 percent at any of three measurements. In addition to lung or pleural involvement by the tumor, the presence of underlying lung disease or cardiac and low performance on the Karnofsky scale were significantly associated with dyspnea. Lung, colorectal, and breast carcinomas were the most common tumor sites in our dyspneic patients and accounted for almost 60 percent of cancer diagnoses in these patients. In 23.9 percent of dyspneic terminal cancer patients, neither lung or pleural involvement nor underlying lung or heart disease could be identified as risk factors.     

Documentation of discussions about prognosis with terminally ill patients

PURPOSE: Previous studies have suggested the importance of communicating with patients about prognosis at the end of life, yet the prevalence, content, and consequences of such communication have not been fully investigated. The purposes of this study were to estimate the proportion of terminally ill inpatients with documented discussions about prognosis, describe the nature and correlates of such discussions, and assess the association between documented discussions about prognosis and subsequent advance care planning. SUBJECTS AND METHODS: Inpatients (n = 232) at least 65 years old who had brain, pancreas, liver, gall bladder, or inoperable lung cancer were randomly selected from six randomly chosen community hospitals in Connecticut. The presence and content of discussions about prognosis, advanced care planning efforts, and sociodemographic and clinical factors were ascertained by comprehensive review of medical records using a standardized abstraction form. RESULTS: Discussions about prognosis were documented in the medical records of 89 (38%) patients. Physicians and patients were both present during the discussion in 46 (52%) of these cases. Time until expected death was infrequently documented. Having a documented discussion about prognosis was associated with documented discussions of life-sustaining treatments (adjusted odds ratio [OR] = 5.8; 95% confidence interval [CI]: 2.8 to 12.0) and having a do-not-resuscitate order (adjusted OR = 2.2; 95% CI: 1.1 to 4.2). CONCLUSIONS: Among terminally ill patients with cancer, discussions about prognosis as documented in medical charts are infrequent and limited in scope. In some cases, such documented discussions may be important catalysts for subsequent discussions of patient and family preferences regarding treatment and future care.     

Urinary incontinence and the terminally ill older person

The principles of managing urinary incontinence in an older patient who has a terminal illness should be based on the general principles of overall care for terminally ill older persons. First, health care professionals need to understand "where" the person is in the dying process. Second, they must be able to predict, with as much accuracy as possible, the consequences of any action or inaction(that is, a decision made not to do an intervention that typically is done). Third, they must understand how the patient's symptom is uncomfortable and bothersome from the patient's standpoint. All three steps need to take into account the family's perception of the patient's discomfort, and, whenever possible, the family should be involved in the decision making.