Abstract

Increasing symptom burden may require intensified pharmacological and non-pharmacological interventions in the terminal phase. In addition, treatment goals have to be reconsidered as patients' needs and priorities may have changed considerably in the terminal phase. Indications for some medical treatment such as chemotherapy, antibiotics or fluid substitution may also change or disappear in the terminal phase. Team discussions may be helpful to evaluate the balance of beneficial and non-beneficial effects of the medicines and facilitate the decision on withholding or discontinuation. Pain intensity in dying patients is not always stable, and an adaptation of the analgesic medication may be necessary as the pain may exacerbate with the progression of the disease or diminish with the deterioration of bodily functions. Patients may have to be switched to short acting application forms to allow flexible dose adaptation. If patients are unable to take oral medications, a switch to subcutaneous application of morphine or hydromorphone is recommended. Pulmonary secretions (death rattle) should be treated with anticholinergic drugs such as hyoscine. Terminal restlessness and agitation should be treated causally whenever possible—for example, with subcutaneous infusions in dehydrated patients. However, most dying patients with terminal restlessness will require symptomatic treatment with benzodiazepines or neuroleptics. As many dying patients will suffer from new symptoms, the standard prescription of a rescue medication for all patients in the terminal phase is recommended. This will allow a rapid response from nurses or other qualified healthcare staff.