Common Symptoms at End of Life and Their Treatment continued...
In dying patients, a poorly understood phenomenon that appears to be distinct from delirium is the experience of auditory and/or visual hallucinations that include loved ones who have already died. Although patients may sometimes find these hallucinations comforting, fear of being labeled confused may prevent patients from sharing their experiences with health care professionals. Family members at the bedside may find these hallucinations disconcerting and will require support and reassurance. Consultation with the patient's or family's minister, rabbi, priest, or imam; the hospital chaplain; or other spiritual advisor is often beneficial.
Terminally ill patients experience a high incidence of fever and infections.[77,78] A number of retrospective studies have shown that a large number of patients who are receiving hospice or palliative care are treated with antibiotics for suspected or documented infections.[79,80,81];[Level of evidence: II]
The benefits and burdens of the use of antimicrobials in this patient population are topics of much discussion.[79,80,82,83] Three prospective studies have suggested that symptom control may be the main objective in the decision to use antimicrobials to treat clinically suspected or documented infections in patients who are receiving palliative or hospice care.[84,85,86][Level of evidence: II]
Difficulties in treating symptoms include predicting which patients will obtain symptom relief and which patients will experience only the additional burdens of treatment. Determining the cause of fever (e.g., infection, tumor, or another cause) and deciding which symptoms from suspected infections might respond to various antimicrobial interventions can be difficult clinical judgments, particularly in patients who have multiple active medical problems and for whom the goal of treatment is symptom control.
Hemorrhage is an uncommon (6%–10%) yet extremely disturbing symptom that can arise from cancer or its treatment.[33,87,88] Patients at particular risk include those with head and neck cancers with tumor infiltration into the carotid artery. Radiation therapy to this region can result in thinning of the walls of the vessels, increasing the risk of bleeding. Slow leakage of blood from eroded areas can signal risk of hemorrhage; however, early signs are frequently not apparent, and bleeding can occur without warning. Other cancers that can lead to sudden hemorrhage include gastric or esophageal cancers that perforate, leading to a rapidly fatal upper gastrointestinal bleed.[33,87] Leukemias and other hematologic disorders place patients at risk for hemorrhage. Disseminated intravascular coagulopathy, idiopathic thrombocytopenia, or other platelet abnormalities can lead to sudden hemorrhage.
When chronic bleeding occurs, management may include hemostatic dressings or agents, radiation therapy, endoscopy, arterial embolization, or surgery may be warranted. Systemic interventions include the use of vitamin K or blood products. However, the goals of care are comfort oriented when catastrophic hemorrhage occurs at the end of life. Optimally, code status has already been discussed; resuscitation is rarely effective. Supportive care is critical, for both the patient and family members at the bedside. Although survival after hemorrhage is very limited (usually a few minutes), patients may be initially aware of events around them. Fast-acting agents such as midazolam may sedate the patient during this distressing event.