End of Life Care

This page refers to the management of patients whose priority is symptom control. 

Definitions

Ceiling of care = highest form of care available to a patient

Symptom control = lowest form of care, offered to all patients

Palliate = out of date term, commonly used to when not for active treatment 

Dying = sings of multiorgan failure and death is predicted 

End of life care = care for less than the last year of life

Ceiling of Care

Largely defined by the location of care available. There are three core locations of care:

1. ICU

2. HDU

3. Ward

4. Home

The level of care, defined by the nursing to patient ratios, largely dictates which interventions are offered. This varies significantly between hospitals!

Interventions per level of care

1.  Intubation, haemodialysis, 1:1 nursing

2. Vasopressor, NIV, 2:1 nursing

3. Ward 

   1. Active care: IV antibiotics, IVF

   2. Symptom care: hospital admission

4. Symptom care at home

Describing Levels of care

All patients will receive a minimal of symptom care and only the fittest patients receive level 1 care. As the patient's frailty increases their ceiling of care falls from ICU to symptom based care. Patients believe the word palliative means 'not for active treatment', however it is possible to receive active treatment whilst under palliative care team. For example, end stage heart failure may still take regular duiresis until very late onto the disease. A better term is lowering the ceiling of care to for active ward care or for symptom based ward care. 

Diagnosis

End of life care: clinical diagnosis, impression active treatment (e.g. antibiotics) will prolong suffering and not result in any meaningful improvement of quality of life. 

Key features

Symptoms & signs

• Poor response to treatments: antibiotics, IVF, other drugs

• Frailty & poor physiologic reserve

• Lack of appetite / PO fluid intake

• Persistent delirium/ confusion/ drowsiness

• Family, nursing or medical concerns within last week of life

Investigations

• Multiorgan failure

  • • Delirium

    • Profound hypoxia

    • Profound hypotension

    • AKI, Oliguira

    • Deranged clotting

• Hypernatraemia

Management

Management in the end of life stage focuses on symptom control rather than therapeutic. For example a DVT is managed with morphine. 

Initial end of life anticipatory medications (vary per trust)

• Antiemetic: 0.5mg haloperidol sc

• Analgesia: 5mg morphine sc

• Anxiolytic: 0.5mg midazolam sc

• Anti-secretions: 20mg hyoscine butylbromide sc

Reasonable starting doses for syringe driver

• 10mg morphine / 24hrs 

• 10mg midazolam / 24hrs

PRN Analgesia

• PRN dose = 1/6th total opioid dose

• PRN 4hrly (6/d)

• Example: if regular = oxycodone 60mg BD

• Total = 120, prn = 20mg 4hlry

Location

Many individuals would like to die at home, however instead die in hospital. This is why advanced care discussions are important in preventing inappropriate hospital admissions. 

Med reg notes

Analgesic considerations

Oxycodone: opioid requirement in AKI

Dexamethasone: liver capsule pain, brain cancer 

Converting opioids

10mg morphine PO equivalence

• 5mg morphine sc

• 5mg oxycodone PO

• 100mg codeine PO

• 4mcg fentanyl patch

Core end of life symptoms

Scottish Palliative Care Guidelines has some excellent resources [1]

• Pain

• Nausea and vomiting

• Excess secretions

• Constipation

Predicting Time Left

This is a common patient question and some clinicians advise specific timescales shouldn't be used. This should certainly be answered sensitively whilst communicating the severity of their illness. Clinicians commonly over estimate how long their patients will live by a factor of 2 in non palliative care doctors and 1.5 in palliative care. 

References and Resources

1. https://rightdecisions.scot.nhs.uk/scottish-palliative-care-guidelines/ 

Written in 2024