The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [60]
Because the insertion of a nasogastric tube is considered a fairly invasive and uncomfortable procedure, it is unlikely to be appropriate for the management of nausea and vomiting in the terminal care setting. Those nasogastric tubes already in situ should remain unless causing distress to the patient
Injectable hyoscine hydrobromide (Buscopan) or octreotide should be considered to dry gastric secretions in those patients with mechanical vomiting secondary to bowel obstruction
Respiratory secretions ‘Noisy’, ‘bubbly’ breathing or ‘death rattle’ in the terminal phase of life affects approximately 50% of dying patients (O’Donnell 1998) and is the result of fluid pooling in the hypopharynx
Changing the position of the patient in the bed may reduce the noisiness of breathing. It is important to reassure the family that the patient is not drowning or choking, and is unlikely to be distressed by the symptom themselves
Antimuscarinic (hyoscine butylbromide) or anticholinergic drugs (glycopyrronium or hyoscine hydrobromide) are often used in this setting and can be administered subcutaneously via a syringe pump
Agitation/restlessness Confusion, delirium, agitation and restlessness are all terms used to describe patient distress in the last 48 hours of life. The symptom is fairly common, with up to 88% of patients experiencing symptoms in the last days or hours of life (Lawlor et al. 2000). Careful assessment should include consideration of any precipitating factors including: medications, reversible metabolic causes, constipation, urinary retention, hypoxia, withdrawal from drugs or alcohol, uncontrolled symptoms and existential distress
Clear, concise communication, continuity of carers if possible, the presence of familiar objects and people and a safe immediate environment can all be helpful nursing interventions
Where the cause of the symptoms cannot be established or cannot be reversed, anxiolytics, antipsychotics or sedation may need to be considered. This may need to be discussed with relatives instead of the patient. It is important that the nurse is present for these conversations in order to facilitate reassurance of the relatives throughout
Breathlessness Breathlessness may be a new symptom in the terminal phase or may worsen from its pre-existing state. Careful assessment is important as this symptom will usually involve physiological, psychological and environmental factors
Low-dose opioids and anxiolytics can be of use for breathlessness, though as with other medications, the route of administration may need to be altered. Nebulized bronchodilators and oxygen may also be of benefit. Where the symptom is causing severe distress and is intractable, sedation may need to be considered in discussion with the patient and relatives
Relaxation exercises, open windows or electric fans and massage may also be of benefit if the patient can tolerate these
Constipation The focus of care with regard to constipation should remain on patient comfort. Oral laxatives are inappropriate if the patient cannot swallow and rectal interventions should only be undertaken if the patient is clearly distressed by this symptom
Preprocedural considerations
Communication
Excellent communication is paramount in all areas of nursing practice, but perhaps most emphatically so in dealing with dying patients and their relatives. Skilful, truthful communication at the end of life affords people the dignity of making educated decisions about the management of their condition and how and where they want to spend their remaining time. Whilst each individual’s information needs will be different and require careful assessment, healthcare professionals tend to underestimate patients’ desire for information and preferences about decision making (Fallowfield 2005). A large UK study showed that the vast majority