Providing comfort is your number-one priority when a terminally ill patient is nearing death. Learn how to manage the common signs and symptoms your patient is likely to experience to make her last moments as peaceful as possible.

AS NURSES, WE play a major role in helping our dying patients get freedom from pain and other distressing symptoms. Managing symptoms in the last phase of life can be especially challenging if you don't have diagnostic studies to help you assess your patient's signs and symptoms. But as a nurse, you bring unique qualities to the table: assessment skills, a partnership with the patient and her family, and the determination to bring comfort.

In this article, I'll present a case study to illustrate the most common end-of-life symptoms, including pain, fatigue, difficulty breathing (dyspnea), and gastrointestinal (GI) problems. Whether your patient has all of these symptoms or a few, you'll learn how to keep her comfortable. First, let's meet our patient.

Meet Mrs. Brown

Margaret Brown, 59, was diagnosed with ovarian cancer 4 years ago. Her treatments have included surgery, several different chemotherapies, and radiation for multiple relapses and chemotherapy-resistant disease. Mrs. Brown now has recurrent, progressive disease that's spread to her liver, and she has a large posterior pelvic mass. After discussing her prognosis and treatment with her oncologist, she's decided to accept home hospice care.

Mrs. Brown's adult daughter, Kristin, greets you when you arrive to introduce them to the hospice program. When you meet Mrs. Brown and perform your initial assessment, you identify what signs and symptoms she needs help managing.

Pain. Mrs. Brown is in bed, lying still and grimacing. She says she has a lot of pain in her abdomen and sides. She describes the pain as a deep ache and rates it as an 8 on a scale of 0 (no pain) to 10 (worst pain imaginable).

You need to address Mrs. Brown's pain before continuing so she can fully participate in the rest of your assessment. Kristin gives her mother a 20-mg dose of morphine sulfate, immediate-release (MSIR), as prescribed by her oncologist and massages her back. In about 25 minutes, Mrs. Brown is comfortable enough to sit up and talk. Now she rates her pain as a 1 or 2.

Fatigue. Mrs. Brown tells you she tires easily and has little energy, so family members have begun doing more for her. She worries that her fatigue will keep her from attending Kristin's wedding in 3 weeks. She says she lies awake at night thinking and worrying, then naps throughout the day. Sometimes during the day she has trouble concentrating on her crossword puzzles.

Ascites. Mrs. Brown says she's surprised that she's gained weight in the past month because she isn't eating much. She wears her bathrobe because her clothes no longer fit over her swollen abdomen.

GI problems. Mrs. Brown says that she's been eating less to avoid "feeling full and nauseated all the time." She used to have a bowel movement every other day, but lately she may go 3 or 4 days before having one. Moving her bowels has also become painful and tiring.

The good news. Mrs. Brown is breathing comfortably and can talk without shortness of breath. Her lung sounds and vital signs are normal. She has no allergies. Her only medications are:

* MSIR, 20 mg every 4 hours as needed

* prochlorperazine (Compazine), 10 mg every 6 hours as needed for nausea

* a multivitamin.

Assessing problem areas

Your initial assessment of Mrs. Brown reveals various distressing symptoms that need attention. Let's consider each one.

Pain. Physically and emotionally distressing, pain varies in its origin, location, intensity, quality, pattern, and even its meaning to each patient. Only the person having pain knows what it feels like. Because pain is subjective, you must always accept the patient's report of pain.

To relieve and prevent Mrs. Brown's pain, do a complete pain assessment now, then reassess her pain at each meeting. Teach her to use a pain-rating scale so you can track her pain and assess the effectiveness of treatment (see Defining pain from every angle).

You identify Mrs. Brown's pain as severe and visceral. You contact her oncologist and get an order for controlled-release morphine (MS Contin), which she'll take every 12 hours. She'll use MSIR for breakthrough pain. Teach her to take medication before the pain becomes intense. She can use breakthrough pain medication as needed, even every hour if she needs it to keep her comfort at an acceptable level. If taking it every hour doesn't control her pain, talk with her oncologist about adjusting her MS Contin dose. Be sure to teach Mrs. Brown and Kristin about adverse reactions to morphine, particularly constipation.

GI problems. Mrs. Brown has been struggling with constipation caused by bowel pressure from her tumor and ascites as well as her pain medication. Constipation can contribute to pain, nausea, vomiting, and anorexia. In someone who's terminally ill, constipation may also be associated with decreased fluid intake, inactivity, weakness, diet changes, elevated calcium in the blood (hypercalcemia), potassium deficiency (hypokalemia), or even lack of privacy. Prevention techniques include stimulant and osmotic laxatives, stool softeners, lubricants, or a combination of these.

Mrs. Brown's oncologist recommends two Senokot-S tablets to be taken at bedtime. This medication is a combination of senna, a stimulant, and docusate, a stool softener. She can increase or decrease the dosage as needed to ensure regular bowel movements every 1 or 2 days. Review the medication and dosage with your patient and teach her to follow the drug regimen as prescribed.

Mrs. Brown's nausea and her "full" feeling may have several causes, such as constipation, slow peristalsis (the rhythmic contraction of smooth muscle that moves contents through the digestive tract), tumor pressure on her stomach, or anxiety. If indicated, metoclopramide (Reglan), 10 mg taken before meals and at bedtime, can accelerate peristalsis; if this isn't effective, she can increase the dose to 20 mg. She can continue to take Compazine as needed to control nausea and vomiting. She may find it easier to tolerate a rectal suppository.

As the patient's symptoms progress, she may not be able to swallow medication. A compound known as ABHR gel-lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol), and metoclopramide (Reglan)-has proven effective for reducing nausea, vomiting, and anxiety at the end of life. The gel is administered by applying it to the patient's inner wrist every 4 to 6 hours as needed. Tell the caregiver to wear gloves when applying it to prevent self-medicating.

Fatigue. Mrs. Brown wants to attend Kristin's wedding in 3 weeks. To help her reach this goal, assess the reasons for her fatigue and help her alleviate it.

Fatigue can result from pathophysiologic factors such as pain, organ dysfunction, and competition between the body and the tumor for nutrients. Possible treatment-related causes include anemia and appetite loss related to nausea or vomiting.

Environmental stressors, such as a room that's too noisy, light, cold, or hot, may keep her awake at night. Emotional stressors include depression, poor sleep, anxiety, and fear.

If fatigue stems from poor sleep at night, a benzodiazepine such as temazepam (Restoril) may be the answer. Zolpidem (Ambien) and zaleplon (Sonata) are other short-acting sleep agents to consider.

To determine the most effective way to relieve Mrs. Brown's fatigue, consult with members of the interdisciplinary team (the hospice physician, nurses, social worker, chaplain, and volunteers) to discover the cause and tailor treatment accordingly. If she has signs of depression, she should be evaluated (see Is your patient depressed?).

Anxious moments

The hospice social worker, Suzanne Ramone, visits with Mrs. Brown and Kristin and conducts a psychosocial assessment. Suzanne helps Mrs. Brown review memorable times in her life and encourages her to talk about her perception of what's happening. Mrs. Brown verbalizes some fears and concerns that are keeping her awake at night. She talks about her funeral and asks what her last days might be like. She agrees to meet regularly with Suzanne to address her anxiety and invites Kristin to participate. The hospice chaplain is available to provide spiritual support; Mrs. Brown says she'll contact him if they'd like a home visit.

After the interdisciplinary team meets, the oncologist reviews Mrs. Brown's current medications and orders dexamethasone (Decadron), 4 mg, at 9 a.m. and 3 p.m. A corticosteroid, dexamethasone, may help ease pain by reducing inflammation and edema around Mrs. Brown's tumor. It can also reduce nausea and vomiting and increase appetite. She may continue to take Compazine as needed.

Instruct Mrs. Brown to take Decadron no later than 3 p.m. because its stimulating effect may keep her awake at night. Continue to assess her pain.

Tackling new symptoms

When you visit again, Mrs. Brown reports some new concerns. She says that although she's taking MS Contin every 12 hours, she wakes up each morning with pain and has been relying on MSIR for breakthrough pain. Even with the medication, she rates her pain a 4. After you consult with her oncologist, he increases her MS Contin dose. She'll continue to take MSIR as needed to manage any breakthrough pain. Teach Mrs. Brown to record how many breakthrough doses she uses each day. Knowing how much breakthrough pain medication she's using will help the interdisciplinary team assess her response to treatment and titrate drug doses.

Mrs. Brown has gotten some relief from nausea and can now eat a few small meals each day. But Kristin is concerned about how large her mother's abdomen is. Mrs. Brown tells you she has more abdominal discomfort, making it hard for her to "get a good breath." She can't zip her bathrobe because of her increased abdominal girth. On assessment, you note that Mrs. Brown has +2 pedal edema.

To relieve her increasing ascites and lower extremity edema, her oncologist orders two diuretics to be taken daily: spironolactone (Aldactone) and furosemide (Lasix).

The ascites is putting more pressure on Mrs. Brown's diaphragm to cause dyspnea. The oncologist orders oxygen at 2 to 3 liters/ minute via nasal cannula as needed for comfort.

Opioids are the best medication for dyspnea in advanced cancer, so you teach Mrs. Brown to use MSIR when she feels breathless. Explain that feeling cool air on her face may give her a sense of more air being available, reducing her perception of breathlessness. Hearing this, Kristin turns the ceiling fan on low in her mother's bedroom, and Mrs. Brown agrees that this helps. A small bedside fan can have the same soothing effect.

Suggest to Kristin that when her mother feels especially short of breath, she can help by sitting with her and breathing slowly and calmly with her to help her relax. Demonstrate breathing in through your nose and out through your mouth. A dose of Ativan can also help relieve the anxiety of breathlessness.

Making plans

Despite the changes in her treatment plan, Mrs. Brown continues to feel fatigued and agrees to accept a nursing assistant's help with personal care. As Kristin's wedding nears, Mrs. Brown worries that she may ruin the day for her daughter if she can't attend the wedding or if she's too tired to enjoy it.

Suzanne, the hospice social worker, visits again to address these concerns. After talking with Mrs. Brown and Kristin, she arranges for a hospice volunteer to spend the afternoon with Mrs. Brown if she's too weak to attend the wedding. Kristin arranges to have the ceremony videotaped so she and her mother can watch the ceremony together later. These contingency plans help Mrs. Brown feel less anxious.

When you visit 3 days later, Mrs. Brown reports she's using four doses of breakthrough MSIR every day. (More than four would indicate a pain crisis.) You inform her oncologist, who increases the MS Contin dose as well as the MSIR dose. As her opioid dose increases, you and the caregiver assess her bowel function daily. If she needs more than 10 Senokot-S tablets a day but isn't able to swallow that many pills, she can take 15 to 30 mL of lactulose, a very effective liquid, once or twice daily. She'll continue to use a laxative suppository as needed.

Relieving the pressure

As pressure on Mrs. Brown's diaphragm increases from ascites, so does her dyspnea. After an interdisciplinary team meeting, the oncologist suggests that Mrs. Brown go to the hospital's short-procedure unit for therapeutic paracentesis, a procedure to drain the fluid accumulated in her abdomen.

You explain to Mrs. Brown that paracentesis should make her more comfortable, but it won't fix the cause of the ascites, which will most likely return. Mrs. Brown discusses the risks and benefits of the procedure with her oncologist and decides to go ahead with it.

Mrs. Brown undergoes an uneventful paracentesis the next morning. She stays on the unit for a few hours afterward and returns home by late afternoon. After the procedure, Mrs. Brown says she's feeling better than she has in days because her breathing has improved.

Five days later, with family at her side, Mrs. Brown attends her daughter's wedding. Both she and Kristin are grateful they can be together on that day.

Keeping her comfortable

The next week, Mrs. Brown spends more time in bed and sleeps more during the day. When awake, she's quiet but oriented and able to communicate her wishes.

Having little appetite, she's consuming mostly liquids and glad that her family isn't trying to force her to eat solid food. Her ascites and dyspnea are returning. She's experiencing some nausea, and she vomited some undigested food twice yesterday. She reports colicky abdominal pain that comes and goes. Assessing her, you find hyperactive bowel sounds and no signs of fecal impaction. Based on your assessment, the oncologist determines that she may have a bowel obstruction (see Dealing with a bowel obstruction).

Surgery isn't an option for Mrs. Brown, who's in the final weeks of life and doesn't want to spend another day in the hospital. The interdisciplinary team focuses on treating the symptoms of her obstruction (pain, nausea, and vomiting) and keeping her comfortable, rather than relieving the obstruction.

The oncologist discontinues Mrs. Brown's laxative medications to lessen the pressure of peristalsis against her obstruction. A patient with a bowel obstruction who's taking Reglan should discontinue it because it can increase peristalsis, abdominal cramping, and pain. Tell Mrs. Brown to sip liquids or suck on ice chips rather than drink large amount of liquids. If her vomiting becomes hard to manage, she should take nothing by mouth. Teach Kristin how to provide her mother's mouth care.

To control pain and decrease Mrs. Brown's pill burden, the oncologist replaces the MS Contin with a fentanyl patch (Duragesic). Teach Kristin to change her mother's patch every 72 hours as directed.

To control breakthrough pain and dyspnea, the oncologist orders liquid morphine (Roxanol), to be given sublingually (under the tongue) as needed, in place of MSIR. You make sure that Mrs. Brown and Kristin know that "as needed" means as often as needed to get relief, even if that's every 30 minutes. You make sure they have morphine suppositories available for breakthrough pain if Mrs. Brown can't tolerate Roxanol.

The oncologist also changes the route for several other drugs. Instead of the oral forms, Mrs. Brown will receive dexamethasone as a topical gel.

The next day, Mrs. Brown's vomiting worsens. She vomits immediately each time she tries to take anything by mouth and rates her abdominal pain as a 6. As ordered, you apply a scopolamine transdermal patch (Transderm Scop) behind one of her ears to relieve spasm-like pain and reduce nausea and vomiting.

The oncologist's orders allow up to three Transderm Scop patches, to be changed every 72 hours. A compounded suppository of ABH (Ativan, Benadryl, Haldol), every 4 to 6 hours, is prescribed to relieve anxiety, nausea, and vomiting. This compound is also available as a gel. The oncologist also orders hyoscyamine (Levsin) in case it's needed to manage secretions.

You and the hospice social worker visit with Mrs. Brown and Kristin to talk about the changes in Mrs. Brown's condition. She's now bedridden, not eating or drinking, and sleeping about 20 hours per day. She recognizes her daughter but isn't able to have a full conversation. Kristin and her mother say "I love you" to each other and Kristin reassures her mother that everything will be okay.

Lessening secretions

You're the on-call nurse two nights later when Kristin calls to report that her mother is "gurgling." Mrs. Brown is completely unresponsive now. Kristin turned her mother onto her side to drain the mucus, but the gurgling has continued. Kristin is afraid her mother will suffocate or choke.

This "wet breathing," once called a death rattle, is common in the final hours or days of life. As Mrs. Brown becomes less responsive, she loses the ability to swallow and clear secretions from her throat and bronchi. Air moving over these secretions makes a gurgling sound. The patient may be unaware of this sound, but it can be extremely distressing to caregivers.

If a patient can cough and raise respiratory secretions, you can encourage her to do so, but she may be unresponsive or too weak. Suctioning the secretions generally isn't recommended for a terminally ill patient because respiratory secretions tend to be low in the throat, and placing a suction catheter deep into the trachea causes discomfort. Anticholinergics such as atropine, scopolamine, and hyoscyamine are effective in diminishing secretions and relieving wet breathing. Educate the family about what to expect and what they can do.

Mrs. Brown already has one Transderm Scop patch applied behind her ear to relieve spasms in her colon and decrease secretions. You advise Kristin to apply a second patch behind her mother's other ear to help decrease the secretions, and to replace the patch every 72 hours.

The additional patch will take 4 hours to start working, so tell Kristin to give her mother one hyoscyamine tablet sublingually. It takes effect in 30 minutes and remains effective for about 4 hours. At that point, the patch will have begun working, and the wet breathing should lessen. Scopolamine dries mucous membranes, so remind Kristin to moisten Mrs. Brown's mouth frequently with moist swabs, a wet washcloth, or lip balm.

Nearing the end

Prepare Kristin for her mother's final hours by describing the signs and symptoms of approaching death:

* breathing that's "wet," slow and shallow, or loud

* urinary changes such as incontinence or minimal urinary output

* increased pain, moaning, restlessness, or agitation that may change to peaceful calm as death becomes imminent

* cool extremities that may or may not appear mottled

* sweating

* brief pauses in breathing (apnea).

This case study demonstrates how dynamic end-of-life care can be. To manage symptoms effectively, continually reassess your patient's condition and adjust the care plan accordingly. Through collaboration with the patient, significant others, and interdisciplinary team members, you can meet your common goal of keeping your patient comfortable at the end of life. LPN

Defining pain from every angle

When you assess your patient's pain, ask questions like these to get a full picture of her pain experience.

* Can you point to the pain or is it everywhere?

* Does it travel? If so, where?

* How do you rate your pain on a scale of 0 (no pain) to 10 (worst pain)?

* How would you describe your pain (dull, aching, lancing, burning, sharp, itching, throbbing, squeezing, or tingling)?

* Is pain always present, or does it come and go?

* Does it come on quickly or build slowly?

* What relieves your pain? What aggravates it?

* What adverse reactions have you had?

* What treatments, including medications and complimentary therapies, have you tried so far? How did each one work?

* What do you think is the reason for the pain?

* How is this pain affecting your life, your emotions, and your relationships?

If a depressed mood is interfering with your patient's quality of life or keeping her from addressing her end-of-life tasks, she should be evaluated for depression. Typical symptoms of depression include severe fatigue, inability to concentrate or make decisions, and feelings of sadness, worthlessness, or extreme guilt.

If she chooses to treat depression, her health care provider may prescribe an antidepressant, often a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil) or sertraline (Zoloft).

Keep in mind, however, that an SSRI may not be the best choice for someone at the end of life, because it may take 4 to 6 weeks to work. For a patient with no time to spare, methylphenidate (Ritalin), a psychostimulant, may be a good alternative. Effective and well tolerated, this drug may bring about an improvement in a day or two.

Dealing with a bowel obstruction

Besides fecal impaction, possible causes of bowel obstruction in a patient with advanced cancer include tumor mass; effects of treatment, such as adhesions from radiation therapy; or medication. Complete or partial obstructions can occur anywhere in the intestine.

Surgery may be appropriate if the patient can tolerate it, if her life expectancy is months (not days), and, most important, if she wants aggressive intervention. Sometimes nasogastric suction is used instead of surgery, but it can be uncomfortable and make breathing and talking more difficult.

On the Web

Economou D. Bowel management: Constipation, diarrhea, obstruction and ascites. In B Ferrell, N Coyle (eds), Textbook of Palliative Nursing, 2nd edition. New York, N.Y., Oxford University Press, 2005.

End of Life: A Nurse's Guide to Compassionate Care. Philadelphia, Pa., Lippincott Williams & Wilkins, 2006.

Johnson DC, et al. Pain and symptom management. Current use of guidelines, protocols, and care pathways for symptom management in hospice. American Journal of Hospice and Palliative Care. 21(1):51-57, January-February 2004.

Kouch M. Managing symptoms for a "good death." Nursing2006. 36(11):58-63, November 2006.