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Last Days of Life (PDQ®): Supportive care - Health Professional Information [NCI] - Symptom Management

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Glycopyrrolate (Robinul) is commercially available parenterally and in oral tablet form. Doses typically range from 1 mg to 2 mg orally or 0.1 mg to 0.2 mg intravenously or subcutaneously every 4 hours, or by continuous intravenous infusion at a rate of 0.4 mg to 1.2 mg per day. Glycopyrrolate is less likely to penetrate the CNS, and fewer adverse effects are reported than with other antimuscarinic agents, though this is probably of little consequence in the use of glycopyrrolate to relieve rattle at the end of life.

Other drugs that can assist with reducing secretions are atropine and hyoscyamine.[59,64] Doses for these agents are included in the table on Common Symptoms at End of Life and Their Treatment. In addition to these agents, diuretics such as furosemide can sometimes eliminate excess fluids that build up in the upper airways. Reducing parenteral fluids can help reduce excess secretions. None of these measures appear to be effective when the underlying cause of rattle is deep fluid accumulation, such as occurs with pneumonia.[65][Level of evidence: II]

Common Symptoms at End of Life and Their Treatment

SymptomManagement
PO = by mouth; prn = as needed; IV = intravenous; SQ = subcutaneous; SL = sublingual.
MyoclonusConsider etiology (usually high-dose opioids administered over a prolonged period).
Hydrate.
Rotate to alternate opioid.
Use benzodiazepines; if patient cannot swallow, use midazolam or lorazepam.
DyspneaUse opioids (small, frequent doses as needed for opioid-naïve patients [e.g., 2.5 mg morphine PO every hour prn]; opioid-tolerant patients will require dose adjustment and upward titration).
Use benzodiazepines only if anxiety is present.
Use glucocorticoids or bronchodilators for bronchospasm.
Use antibiotics if cause is infectious and this is consistent with goals of care.
Use oxygen only when hypoxia is present.
Direct a cool fan toward the face.
Reposition (elevate head of bed; if patient has nonfunctioning lung, position on side with that lung down).
Use cognitive-behavioral therapies such as guided imagery.
Use integrative therapy such as acupuncture.
FatigueUse methylphenidate (Ritalin) 2.5 mg twice daily (in a.m. and at noon) to start; increase up to 30 mg/day; anxiety and restlessness may occur.
Use d-amphetamine (Dexedrine) 2.5 mg/day to start; increase up to 30 mg/day; anxiety and restlessness may occur.
Use modafinil (Provigil) 50–100 mg/day to start; increase to 100–200 mg/day.
Suggest energy conservation methods.
Employ sleep hygiene measures.
(Refer to the PDQ summary onFatiguefor more information.)
CoughConsider etiology (infection, bronchospasm, effusions, lymphangitis, cardiac failure) and treat accordingly.
Use opioids (small, frequent doses to start for opioid-naïve patients; opioid-tolerant patients will require dose adjustment and upward titration).
Use other antitussives such as guaifenesin or dextromethorphan.
Use glucocorticoids such as dexamethasone to manage cough due to bronchitis, asthma, radiation pneumonitis, and lymphangitis.
Use bronchodilators such as albuterol 2–3 inhalations every 4–5 hours for bronchospasm leading to cough.
Use nonsedating antihistamines with or without decongestants for sinus disease. (Suggest nonsedating agents if fatigue or sedation is a problem.)
Use diuretics to relieve cough due to cardiac failure.
(Refer to the PDQ summary onCardiopulmonary Syndromesfor more information.)
RattleUse scopolamine transdermal patch, 1.5 mg (start with one or two patches; if ineffective, switch to 50 µg/hour continuous IV or SQ infusion and double the dose every hour, up to 200 µg/hour).
Use glycopyrrolate, 1–2 mg PO; or 0.1–0.2 mg IV or SQ every 4 hours; or 0.4–1.2 mg/day continuous infusion.
Use atropine, 0.4 mg SQ every 15 minutes prn.
Use hyoscyamine, 0.125–0.25 mg PO or SL every 4 hours.
Change position or elevate head of bed.
Reduce or discontinue enteral or parenteral fluids.
Avoid suctioning.
DeliriumStop unnecessary medications.
Hydrate.
Use haloperidol, 1–4 mg PO, IV, or SQ every 1–6 hours prn.
Use olanzapine, 2.5–20 mg PO at bedtime.
(Refer to the PDQ summary onDeliriumfor more information.)
FeverUse antimicrobials if consistent with goals of care.
Use antipyretics such as acetaminophen.
Apply cool cotton cloths.
Give tepid sponge baths.
HemorrhageUse vitamin K or blood products for chronic bleeding if consistent with goals of care.
Use aminocaproic acid (PO or IV).
Induce rapid sedation with IV midazolam when catastrophic hemorrhage occurs.
Use blue or green towels to minimize distress.
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