Though patients usually die peacefully, problems may arise in the last period of a terminal illness. In the final days new symptoms may arise or there may be exacerbation or recurrence of symptoms previously well controlled. Two hundred consecutive hospice patients were studied. The incidence was noted of pain, dyspnea, moist breathing, nausea and vomiting, confusion, restlessness, jerking and twitching, difficulty in swallowing, incontinence and retention of urine, sweating, moaning and groaning, and loss of consciousness. Each symptom is considered and the results of the management employed are noted. Many of the features appearing in the last days of a terminal illness, especially cancer, can be attributed to organic brain disease consequent to metabolic disorder associated with multi-organ failure. An awareness of the nature of the problems that may arise in the last 48 hours of life makes it possible to keep the patient comfortable to the end.
A wide variety of causes may be responsible for nausea and vomiting in terminal illness. The different emetic stimuli reach the vomiting centre by a variety of pathways and can be blocked by specific antiemetics that act at the neurotransmitter receptor sites in these pathways. A knowledge of the neurotransmitter receptor antagonist potency of the different antiemetics allows the choice of the most appropriate antiemetic for the relief of the nausea and vomiting caused by a particular emetic stimulus. To demonstrate the efficacy of this approach to the management of nausea and vomiting in terminal illness, the outcome of antiemetic choice in 100 consecutive episodes is recorded.
The feeling that life has had no meaning is an impediment to a peaceful death. Life review enables a person to identify events that have been of worth and so enhances self-esteem. This approach has been extended and formalized by establishing a biographer service to compile oral and written biographies of patients who may be expected to benefit from such a re-examination of their lives. The service is now also being offered to patients whose disability precludes most other forms of activity. The value of biography as therapy is considered and it is concluded that it has much to offer in the circumstances described.
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