Managing The Actively Dying

Dying patients require symptom management, physical expressions of love, the presence of significant others, truth telling, and dignity through meticulous maintenance of personal hygiene.98,99 Patients should not be subject to venipuncture and procedures for curiosity sake when the goals of care are "comfort." Family education, frequent visits, and intensive low-technology care are other elements to good end of life care. Symptoms change during the course of illness. At the end, pain, delirium, nausea, vomiting, and secretions are the important symptoms to control.99-101 Opioids should be maintained despite changing mentation. Families often mistake the dying process for drug toxic-ity and need to understand the difference. Terminal agitation or restlessness may arise from a full rectum or bladder, poorly controlled pain, or delirium. Patients should be examined for fecal impaction and a distended bladder, and measures should be taken to relieve either one if present. As patients become more nonverbal, the therapeutic decision regarding terminal agitation is between adjusting the opioid or the neuroleptic. Families may be helpful in deciphering pain behaviors. However, in the end it is a trial of one or the other.99-101 We have used chlorpromazine for terminal delirium, while others have used a combination of haloperidol and a benzodiazepine, usually lorazepam or midazolam. Both chlorapromazine and haloperidol treat nausea and vomiting. Individual doses of chlorapromazine are 12.5-25 mg parenteral or per rectum titrated to response. Doses may range from 25 to 200 mg every 4-6 h. Secretions respond to antimuscarinics. Once secretions are clinically evident, antimuscarinics should be given around the clock, with dosing similar to opioids in pain management. Glycopyrrolate 0.1-0.2 mg intravenous or subcutaneous every 4-6 h is a reasonable choice. Terminal sedation is occasionally necessary for refractory delirium or dyspnea. Phenobarbital 100 mg intravenous or subcutaneous every 8 h up to 1200 mg over 24 h has been our choice for sedation.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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