Care of the Imminently Dying Patient and End-of-Life Care
Recognizing dying
Clues include Palliative Performance Scale around 30% or less, bedbound status, minimal oral intake, dysphagia for pills, mottling, cool extremities, oliguria, Cheyne-Stokes respiration, terminal restlessness, and audible secretions. These signs are imprecise individually; the pattern matters.
The active dying plan
Stop non-beneficial interventions: routine labs, vital-sign monitoring, statins, vitamins, hypoglycemics, antihypertensives, anticoagulants, and other preventive medications. Convert essential drugs to a route that still works - sublingual, buccal, subcutaneous, rectal, transdermal, or an existing line. Continue the medications that control symptoms: opioids, anticholinergics, antipyretics, anxiolytics. Add anticipatory prescriptions so no one waits for a pharmacy at 2 a.m.
Refractory symptoms and sedation
Terminal restlessness: exclude pain, urinary retention, fecal impaction, and medication effects, then treat with a benzodiazepine or antipsychotic. Palliative sedation for a genuinely refractory symptom is proportionate, requires informed consent from patient or surrogate, and intends relief of suffering - ethically distinct from euthanasia and assisted death. Terminal secretions are managed with anticholinergics and repositioning; deep suctioning usually causes more distress than it relieves.
Hydration and nutrition
There is no evidence that artificial hydration or nutrition prolongs survival or improves comfort at the end of life, and both can worsen edema, secretions, and dyspnea. Thirst and dry mouth are managed with ice chips, swabs, and lip balm - a common exam trap is the belief that dehydration itself causes suffering.
Rule of thumb: if a medication will not change how the patient feels, breathes, or interacts within days, stop it and say why out loud to the family.