Quick Consults

When weighing end-of-life interventions in progressive life-limiting illness, it is usually helpful to consider the hoped-for goals and whether the intervention is expected to achieve them. With feeding, there are various goals people might seek, such as: Preventing hunger. Preventing malnutrition―Malnutrition is a physiological term and does... 

Refractory edema in advanced metastatic cancer is one of the more challenging clinical problems. Diuretic therapy tends not to be particularly effective. Occasionally, there may be contributing factors that can be fully or partially addressed. There may be inferior or superior vena cava obstruction by clot (for which anticoagulation may be... 

Odour from wounds results from bacteria that reside in necrotic wound tissue. Odour associated with malignant fungating wounds can be upsetting and may contribute to the suffering of the patient and the family. Fungating wounds also present challenging management issues for health care providers.   Based on clinical practice and a review of... 

There are no specific best practice guidelines on the use of oxygen at the end of life. The first distinction that must be made is between the use of oxygen in unconscious and conscious patients. Frequently, oxygen is continued in patients who are deeply unconscious and in their final hours of life. As with all interventions, it is important... 

Constipation is a very common symptom in patients with advanced disease of any kind, including cancer. Patients at the end of life have many reasons for becoming constipated, including immobility, reduced fluid intake, and the use of a number of medications. Patients frequently need to have bowel movements in inconvenient and unfamiliar places,... 

Information is limited regarding the long-term use of polyethylene glycol (PEG). Some of the information available suggests that it is the most effective for the first 14 days of treatment. However, geriatric resources produced by the American Society of Consultant Pharmacists suggest continuing the use of PEG if it still meets your therapeutic... 

First, there is room to increase the Senokot dose to eight tablets daily at bedtime. If this is not effective, it is possible to introduce polyethylene glycol and decrease the daily Senokot dosage. Sennosides (such as Senokot) and osmotic laxatives (such as polyethylene glycol or Lactulose) have a different mechanism of action. If the response... 

Dyspnea is a common symptom in end-stage heart failure, and, in addition to optimizing cardiac medications, opioids can be very effective in reducing the sensation of air hunger. However, there is often some reluctance to prescribe opioids in patients with respiratory compromise, and there is some conflicting information about the safety of... 

Bisacodyl (Dulcolax) belongs to the same therapeutic class as sennosides (a stimulant laxative that acts on the intestinal wall to promote motility and bowel movement). The onset of action for bisacodyl tablets is approximately 10―12 hrs, and the bisacodyl suppository is approximately 15 minutes. If you are using the tablets, use a similar... 

Polyethylene glycol (PEG) is an osmotic laxative . It acts by absorbing more moisture into the stool, increasing the fecal volume, and inducing a laxative effect. The typical onset of action for Miralax is 1―2 days for constipation and 1―3 days for fecal impaction . It is contraindicated in severe inflammatory intestinal conditions and intestinal... 

Sennosides is a mixture of two naturally occurring plant glycosides (sennosides A and B). It works in the large intestine, acting directly on the submucosal plexus and the deeper myenteric plexus to stimulate propulsive waves. The typical onset of action for sennosides is 6―12 hours. Ideally, it should be taken at bedtime, with an expectation... 

Docusate is a surface-wetting agent, more commonly known as a stool softener . If prescribed, it should always be combined with a stimulant like Senokot. Current published literature indicates that patients usually respond as well to sennosides alone as they do when sennosides are combined with docusate. One of the few times when docusate... 

Fever is a common symptom at the end of life. It can mean there is an infection, which often indicates an end-of-life pneumonia. But fever may also be associated with other causes, such as a cytokine-induced fever produced by a cancer, which is referred to as “tumour fever.” The investigation and/or treatment of fever is based on life expectancy... 

If reversible issues may be causing or contributing to nausea, these will need to be addressed if possible and appropriate. These may include the following: medication side effects (consider switching from hydromorphone to a fentanyl patch); severe constipation (consider an abdominal X-ray if one has not been done); metabolic abnormalities... 

End-stage secretions (commonly referred to as “death rattle”) is known to occur in between 12 and 92 percent of patients, with the median time from onset of death rattle until death between 11 and 28 hours. A question around secretions is whether they originate from the throat and salivary glands, or from the lower respiratory tract, possibly...