62 2.7.5 Pain and Symptom Management

At the end-of-life, the most common symptoms include:

• Dyspnea
• Pain
• Agitation and delirium
• Anxiety and depression
• Airway secretions

The progression of these symptoms may vary within a few hours because death time is unexpected but the pace to approaching death may be quick. Assessment and provision of psychosocial and spiritual needs is critical throughout the LTC stay.^[1]

Pain:

• For severe pain, oral morphine, hydromorphone or oxycodone are first line options
• Consider both regular and breakthrough doses for dose adjustment considering safety according to each resident’s situation
• Breakthrough doses are generally 10% of the total opioid dose/day
• Optimize opioid therapy before adding adjuvants e.g., antidepressants, anticonvulsant etc.

Dyspnea:

• Identify and treat reversible causes as possible
• Provide fresh air when O2 levels are satisfactory
• utilize non-pharmacological intervention because dyspnea may not be due to hypoxia
• Opioids are first line for medication management
• Bronchodilators may be used for mild dyspnea
• Corticosteroid trial may be used
• Benzodiazepines with opioid can help with anxiety/panic in severe distress^[2][3][4]

Respiratory Congestion/Oral Secretions

• Noisy breathing, respiratory tract secretions or death rattle is the noise produced with breathing due to residents’ inability to swallow saliva or a respiratory infection at the end-of-life
• It may cause agitation and a feeling of suffocation in an alert person and distress in care partners and health care providers
• Institute non-pharmacological interventions:
• humidity, mouth care, frequent repositioning, and avoid suction if possible (can cause agitation)
• Subcutaneous and transdermal anticholinergic therapy
• If fluid overload, consider diuretics

Refractory Symptoms and Palliative Sedation

• Offer palliative sedation for dying patients when symptoms remain unrelieved and cause suffering for them
• It should not be utilized relieve care partners’ or health care providers’ discomfort
• Utilize palliative sedation only when there is limited prognosis and other interventions such as artificial nutrition, hydration, unnecessary medications and bowel interventions may have been discontinued