![]() 2, 11, 19, 20Ĭontinuous pain in the semiconscious patient might be associated with grimacing and facial tension. Symptomatic treatment might be more appropriate and includes oxygen, opioids to control pain and dyspnea, anticholinergic drugs such as atropine to reduce respiratory secretions, and benzodiazepines or antipsychotics to reduce fear and agitation ( Table 1). 18 On the other hand, antibiotics do not always improve comfort, and aggressive approaches (eg, intravenous antibiotics and hospitalization) might decrease comfort. On the one hand, antibiotics might extend the number of days lived with relative discomfort. However, this might not be a good idea if the goal of care is symptom control without life prolongation. 16, 17 Antibiotics can be used to increase comfort even when death is imminent. Available from: Pneumonia is associated with high levels of discomfort, with distressing symptoms occurring more frequently than in patients who die after food and water intake problems. Reproduced from van der Steen et al, 15 with permission from the EMGO Institute for Health and Care Research. ©2008 EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands. Prognostic score to estimate risk of death within 14 d in patients with dementia and lower respiratory infection or pneumonia when treated with antibiotics To alleviate symptoms of dry mouth and thirst, mouth care consisting of oral cleaning with swabs and lubrication is recommended every 2 hours. Families who fear that the patient might suffer from thirst should be reassured: the correlation between hydration and thirst status in terminally ill patients is modest. If the effort to eat and drink is too draining or unwelcome, the patient should not be pressured to make this effort. 10 However, it must be acknowledged that there are different approaches worldwide that are dependent on the beliefs or attitudes of medical providers and local culture.ĭehydrated patients who are still capable of swallowing should be offered oral fluids and small quantities of food as tolerated. Although use of intravenous or subcutaneous clysis might be temporarily useful, many experts think that, in a terminal patient for whom hydration is of questionable value, it might be appropriate to withhold or withdraw this treatment in order to avoid discomfort (prolongation of dying, increased sputum retention). It is not rare that dehydration is diagnosed only with marked degrees of volume depletion typically associated with hypernatremia and uremia. In advanced dementia, the symptoms of dehydration are often nonspecific. Here is an example of a comfort feeding–only order: 9 It offers a clear goal-oriented alternative to tube feeding and eliminates the apparent care–no care dichotomy imposed by current orders to forgo ANH. Such an order states what steps are to be taken to ensure the patient’s comfort through an individualized feeding care plan. There is still a risk of aspiration but it is minimized if the feeding is stopped when the patient shows signs of distress.Ī “comfort feeding only” order has been proposed. Providers must explain to families that careful hand feeding should fill patients’ needs without subjecting them to invasive and nonbeneficial artificial feeding. Cultural and moral standards often impede families from being able to withhold artificial support. This alternative is more aligned with comfort, allows social interaction, and avoids the complications of tube feeding. Comfort feeding, or hand feeding, involves giving patients frequent small amounts of food, sips of liquids, or mouth care. Findings of studies in which terminally ill patients still capable of reporting their symptoms were interviewed show that, although it does not provide adequate nutrition, “comfort feeding” is able to eliminate feelings of hunger or thirst. ![]() Concern about the patient suffering from hunger and thirst is common among families considering tube feeding. ![]()
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