Nausea

The pathophysiology underlying nausea in a dying patient is often multifactorial and can include drugs, organ failure, metabolic disorder, obstruction, constipation, gastroparesis, inflammation, and tumors, to name a few. Nausea is usually treated based on suspected etiology; however, empiric antiemetic therapy has been shown to be equally effective.^11,12

Secretions

The “death rattle” refers to the sound that is made when air passes through a dying patient’s pooled secretions within the posterior oropharynx. The rattle is not harmful to the dying patient but is often the most distressing symptom to the family. Proper positioning can facilitate drainage of secretions, but atropine and glycopyrrolate (a quaternary amine that does not cross the blood-brain barrier and therefore does not contribute to terminal delirium) are appropriate drugs in the acute setting to decrease secretions and mitigate noisy respiration.⁵ Aggressive suctioning should be avoided in the dying patient as comfort of the patient is the goal.

Anxiety, Agitation, and Delirium

Haloperidol has the best data in treating agitation or delirium in this patient population.  Droperidol may also be effective, but there is less evidence to support its use. Benzodiazepines can cause paradoxical agitation in elderly patients and should be used as a second-line option with close monitoring of the patient.^5,8 If terminal delirium is refractory to initial medications, consult a palliative physician to assist with palliative sedation.

Case Conclusion

You are able to find a quiet room for the patient and his family. You place a nasal cannula for comfort and review the patient’s opioid home regimen as 60 mg extended-release morphine sulfate BID with a rescue dose of 20 mg every four hours for a total oral morphine equivalent of 240 mg that can be converted to 80 mg (3:1 PO:parenteral) in a 24-hour period. Because the patient is not opioid-naive, you give his typical home dose with a 50 percent reduction (10 mg IV) and write for an additional 50 percent of his breakthrough pain dose (3 mg IV) to be given every 30 minutes PRN for severe pain. This dose of opioids will also help manage his dyspnea. For nausea, you select ondansetron 4 mg. Physicians should use an online opioid conversion calculator, such as https://clincalc.com/opioids or https://opioidcalculator.practicalpainmanagement.com, or consult their ED pharmacist when converting oral to IV opioid formulations. 

After your interventions, the patient appears much more calm and comfortable. His heart and respiratory rates come down. The patient dies comfortably with family at bedside less than an hour later. They are very appreciative of the care and support provided by the emergency team.