Pharmacotherapy During the End of Life: Caring for the Actively Dying Patient
Jonathan G. Leung PharmD, BCPS, BCPP
Sarah Nelson PharmD, BCPS
Megan Leloux PharmD, BCPP
Earnest Alexander PharmD; Department Editors
Gregory M. Susla PharmD; Department Editors

AACN Advanced Critical Care
June 2014 
Volume 25  Number 2
Pages 79 - 88
  PDF Version Available!

Knowledge of pharmacotherapy interventions provided at the end of life is crucial to optimize care of actively dying patients. As the objective of care shifts from life-prolonging measures toward comfort measures, several challenges may arise. The use of less-familiar medications, barriers to medication administration, and inappropriate pharmacotherapy at the end of life can have deleterious results. Although goals of treatment may vary between patients, some issues related to end-of-life symptom management are common. These issues include, but are not limited to, the management of pain, death rattle/hypersecretion, delirium, agitation, and dyspnea. The ability to recognize end-of-life symptoms allows the health care professional to avoid a delay in providing maximal patient comfort. This column discusses barriers to medication administration and pharmacological agents that can be used to manage actively dying patients.The inability to administer a medication at the end of life is a barrier to providing adequate patient care. Intravenous (IV) access may be discontinued as a result of end-of-life goals, and oral access may be limited because of impaired swallowing ability or altered mental status. In the absence or limited availability of IV and oral access, alternative routes of medication administration can be used. Alternative medication formulations used at the end of life can allow medications to be delivered buccally, sublingually, rectally (PR), as nebulized inhalations, transdermally, or topically (Table 1). In emergent situations or when alternative routes of administration are not possible, non-IV parenteral routes may be considered.Liquid concentrates are used to deliver therapeutic doses of medication orally in very small volumes and include, but are not limited to, dexamethasone, morphine, methadone, and lorazepam.1 These formulations are up to 10 times more concentrated than standard liquid solutions, and some can be identified by the proprietary name Intensol

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