--- module: 068-02 language: en chapter: 68 title: "Palliative Medicine, Symptom Control, Dying, Grief, and Bereavement" module_title: "Advanced symptom reasoning, opioid safety, treatment withdrawal, and care in the final phase" source_sha256: 7291cc40a47331fab1eeb14d1a8cea2cac033a7d81c70b221a8dcb53a4d4c215 --- # Advanced palliative reasoning and final-phase care ## Symptom reasoning and total suffering ### Do not dismiss symptoms as inevitable ### Useful only if comfort, function, or goals improve ### Ask mechanism, reversibility, burden, time, impact #### Prevents neglect and reflex intervention ### Dimensions of total suffering interact #### Breathlessness and panic amplify each other ### Scores track but cannot replace narrative ## Pain assessment and opioid prescribing ### Background versus incident and breakthrough pain ### Recognise cord compression, fracture, retention #### Targeted treatment may prevent catastrophe ### Start from exposure, route, organ function, frailty ### Repeated rescue: uncontrolled pain or new cause #### Blind escalation worsens hyperalgesia, delirium ### Conversions are population estimates #### Reduce for cross-tolerance, then titrate ### Kidney failure accumulates active metabolites ### Transdermal onset and offset are delayed ### Syringe infusion does not imply imminent death ## Opioid toxicity and home safety ### Drowsiness, hallucination, myoclonus, touch pain #### Suspect accumulation, not only progression #### Reduce dose, switch drug, or trial fluid ### Reassess arousal, breathing depth, pain ### Teach family the signs of overdose ### Plan storage, error prevention, returns ## Bowel and nausea ### Prophylaxis accompanies regular opioids ### Overflow diarrhoea may conceal impaction ### Distinguish partial from complete obstruction #### Prokinetic worsens colic in complete block ### Treat nausea by mechanism ### Combine complementary agents #### Stacking similar receptor effects adds harm ## Breathlessness and secretions ### Severity correlates imperfectly with saturation ### Airflow and calm plan reduce threat perception ### Oxygen for symptomatic hypoxaemia #### Tubing may burden non-hypoxaemic patients ### Careful opioid titration is not euthanasia ### Secretion sounds may not mean suffering #### Avoid deep pharyngeal suction ### Judge distress by face, tension, restlessness ## Delirium, family, and sedation ### Delirium fluctuates, hypoactive often missed #### Seek pain, retention, infection, withdrawal ### Picking behaviour is brain failure, not rejection ### Exhausted vigil: share tasks, respite, contacts ### Ask the patient directly how much to know ### Agitation near death: reassess reversible causes ### Palliative sedation only for refractory suffering #### Minimum effective depth, titrated to relief ## Deprescribing, nutrition, and hydration ### Deprescribing is an active intervention ### Distant prevention adds burden without benefit ### Taper drugs where abrupt stopping harms ### Explain stopping to prevent sense of abandonment ### Feeding symbolises care #### Reduced intake reflects metabolism, not neglect ### Tube feeding adds aspiration and line infection ### Mouth care, ice, sips often relieve thirst ### Hydration trial needs endpoints and stopping rule ## Recognising dying and arrest plans ### Trajectory and repeated review, not one sign ### Reversible causes may mimic dying ### Guide family on breathing, cool limbs, contacts ### Arrest plan defines each treatment separately #### Not resuscitating is not stopping care ### Home death: verifier, contacts, documents ### Anticipatory orders with ranges and maximums ## Withdrawing life-sustaining treatment ### Same question as withholding: benefit to goals ### Stage reduction of ventilation, pressors, dialysis ### Titrate analgesia and sedation pre-emptively ### Add medication for observed distress #### Not for numbers or timing of death ### Delayed death is not necessarily a wrong decision ## After death, planning, and handover ### Verification, respectful handling, certification ### Correct guilt about medication, food, withdrawal ### Proportionate bereavement follow-up #### Assess suicidality, isolation, disabling yearning ### Plan before crisis, prescribe before swallow lost ### Palliative medicine is not less medicine ### Handover: goals, capacity, medicines, contacts #### Amounts used in the previous 24 hours ### Patient should not repeat a distressing account