Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life—A Systematic Literature Review

Abstract

There is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients, and the reviewed evidence provides limited guidance for clinicians to assist in a distinct and significant phase of life.

A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition

“…End-of-life caredpharmacological symptom control Adults Outcome: quality of care 1 SR 123 One review examining a range of palliative interventions and outcomes concluded that there is a lack of evidence concerning the effectiveness and safety of palliative drug treatment in dying patients. No evidence was found for scopolamine hydrobromide and atropine for death rattle; some evidence was found supporting the use of morphine and midazolam for dyspnea, anxiety, or terminal restlessness; and some support was found for morphine, diamorphine, and fentanyl for pain.…”

Retrospective chart review to assess domains of quality of death (recognition of dying, appropriate limitations, symptom monitoring, anticipatory prescribing) of patients dying in the acute hospital under the care of a nephrology service with renal supportive care support over time

“…The most commonly prescribed drugs were generally opioids and benzodiazepines, although anti‐cholinergics were also frequently prescribed at SGH. Whilst there is no convincing evidence for the use of anti‐cholinergics in terminal respiratory secretions, the practice is quite common in palliative care …”

“…Whilst there is no convincing evidence for the use of anti-cholinergics in terminal respiratory secretions, the practice is quite common in palliative care. 19 Cessation of observations and non-essential medications was quite low, likely reflecting the acute hospital environment where observations are not just routine but, at times, even required (unless otherwise documented).…”

Communication with Families in the Last Days of a Patient’s Life and Optimal Delivery of a Death Pronouncement

“…The effect of morphine on alleviating dyspnea has been well investigated [26]. Because of the deteriorated capacity of drug metabolism and excretory abilities during the end-of-life period, the administration of morphine requires careful monitoring of adverse events (e.g., impaired conscious state and decreased respiration rate) [26].…”

“…The effect of morphine on alleviating dyspnea has been well investigated [26]. Because of the deteriorated capacity of drug metabolism and excretory abilities during the end-of-life period, the administration of morphine requires careful monitoring of adverse events (e.g., impaired conscious state and decreased respiration rate) [26]. Given the concerns of those adverse events, physicians are less confident with prescribing opioids for dyspnea than for pain, which can result in the undertreatment of dyspnea [27].…”