Terminally ill cancer patients near the end of life can experience refractory symptoms, which require palliative sedation. Midazolam is the most common benzodiazepine used for palliative sedation therapy.
Anticipatory medicines are sometimes also called end of life medicines or just in case medicines.
The most commonly prescribed drugs include acetaminophen, haloperidol, lorazepam, morphine, and prochlorperazine, and atropine typically found in an emergency kit when a patient is admitted into a hospice facility.
Palliative sedation is an option of last resort for the people whose symptoms cannot be controlled by any other means. It is not a form of euthanasia or physician-assisted suicide, as the goal of palliative sedation is to control symptoms, rather than to shorten or end the person's life.
Sedation and agitation
The patient will commonly be started on a small dose of sedative (such as a benzodiazepine like midazolam or lorazepam). They may also be given an anti-psychotic (such as haloperidol).
Morphine is an opiate, a strong drug used to treat serious pain. Sometimes, morphine is also given to ease the feeling of shortness of breath. Successfully reducing pain and addressing concerns about breathing can provide needed comfort to someone who is close to dying.
Palliative sedation is a measure of last resort used at the end of life to relieve severe and refractory symptoms. It is performed by the administration of sedative medications in monitored settings and is aimed at inducing a state of decreased awareness or absent awareness (unconsciousness).
Muscle spasm. Parenteral benzodiazepines, such as midazolam, can be used to relieve muscle spasm and spasticity in the last days of life (Table 3).
Terminal agitation is typically seen during the hours or days before death and can be distressing and overwhelming for caregivers.
Syringe drivers are indicated when other routes become inappropriate or difficult. They are generally programmed to deliver their contents over 24 hours. Morphine, midazolam and cyclizine are common examples of drugs given in this way, but not all medicines are suitable to be administered via a syringe driver.
A bystander hands a medicine bottle to the attending paramedic frantically saying, “They drank this! They drank this!” The bottle contains digoxin 100 mg, diazepam 1,000 mg, morphine 15,000 mg, amitriptyline 8,000 mg and phenobarbital 5,000 mg.
The end-of-life period—when body systems shut down and death is imminent—typically lasts from a matter of days to a couple of weeks. Some patients die gently and tranquilly, while others seem to fight the inevitable. Reassuring your loved one it is okay to die can help both of you through this process.
End of life care should begin when you need it and may last a few days or months, or sometimes more than a year. People in lots of different situations can benefit from end of life care. Some of them may be expected to die within the next few hours or days. Others receive end of life care over many months.
Metabolic failure: The kidneys, the liver, and other organs begin to fail near the end of life, and the physiological issues these events cause can interfere with brain function and result in delirium, restlessness, and agitation.
People who take EOLOA medications typically fall into a deep sleep within 10 minutes of administration, followed by coma, respiratory depression, and death shortly thereafter. Typically, death occurs within two to five hours of ingestion.
Haloperidol is a butyrophenone derivative and dopamine antagonist. It is commonly prescribed for nausea, vomiting, and delirium in hospice/palliative care. Its use in delirium occurs despite little placebo controlled evidence that antipsychotic medication changes the natural history of delirium.
Myth: Palliative sedation hastens death. Fact: It is disease progression that causes the body to gradually shut down and eventually die. Patients with poorly controlled pain, shortness of breath, and agitation actually die sooner because of the stress caused by this suffering.
A conscious dying person can know if they are on the verge of dying. Some feel immense pain for hours before dying, while others die in seconds. This awareness of approaching death is most pronounced in people with terminal conditions such as cancer.
(higher doses of morphine may be appropriate if the patient is already receiving regular strong opioids for pain). Combining opioids and midazolam to manage breathlessness and anxiety in the last days of life is common practice in palliative care.
Terminal restlessness generally occurs in the last few days of life. Around 42 percent of hospice patients experience agitation during their final 48 hours. But even more develop symptoms before then, which may not subside until death.
Midazolam is a commonly used benzodiazepine in palliative care and is considered one of the four essential drugs needed for the promotion of quality care in dying patients. Acting on the benzodiazepine receptor, it promotes the action of gamma-aminobutyric acid.
Can patients hear us when they are very asleep? It is possible that patients can hear and feel what is going on around them, even when apparently unconscious, but they might be too sleepy to respond when we speak to them or hold their hand.
In most cases with CPST, sedation continues until death. In rare cases, however, patients may be woken up at some point, according to Downar.
Dying patients unable to take oral medication
†Midazolam 20mg to 30mg via continuous subcutaneous infusion (CSCI) over 24 hours can be used as maintenance therapy.