Guidelines for a Palliative Approach in Residential Aged Care

a problem [401] (Level EO). (Information on the pharmacological and non-pharmacological
management of pain has already been provided (see Section 6.2, ‘Pain management’) and is
not restated here). All residents who are dying are at risk of rapid skin breakdown, and the
associated discomfort should be avoided by proactive management. If turning the resident
to relieve pressure causes them distress, then turning should be avoided, unless the position
change ultimately leads to greater levels of comfort [402] (Level EO). (See also Section 6.10, ‘Skin
integrity’, for further discussion of skin care and the use of special mattresses). However, it is
also important to consider the close tactile comfort of gentle repositioning. For a very small
number of residents with advanced cancer there is a risk of catastrophic terminal haemorrhage
(e.g. erosion of a large artery). Planning for this event is important so that if haemorrhage
occurs then medications to lessen pain and agitation are readily available. An opioid such as
morphine and/or a benzodiazepine such as midazolam are recommended. [109]
14.4.2 Delirium, restlessness and sedation
Delirium is commonly associated with agitation or restlessness. However, there are difficulties
with defining restlessness and delirium [403] (Level EO). (See Chapters 5, ‘Advanced dementia’ and
7, ‘Psychological support’ for further discussion of issues relevant to cognitive impairment). Yet, if
delirium goes undiagnosed or is poorly managed then the family and health care practitioners will
have unpleasant memories of the resident’s death [327,404] (Level QE; Level III-2). Common signs of
delirium and restlessness include:
• pulling at bed clothes;
• frequent changes of position (being unable to relax physically);
• myoclonus;
• moaning; and
• calling out (often incoherently)
Management of delirium involves addressing reversible causes (such as urinary retention and
constipation) and medication side effects. [404] The common pharmacological intervention for
delirium is haloperidol and the benzodiazepine drug, clonazepam. [109] Clonazepam is a longacting
agent and can assist in easing restlessness. It can be administered in droplet format
sublingually or subcutaneously. Sedation in end-of-life care is warranted when symptoms
are unrelieved (including existential or psychological distress). There are, however, various
levels of sedation, and medications should be titrated according to effect [405,406] (Level III-3;
Level EO). For recommended doses of sedating medications see the Therapeutic Guidelines:
Palliative Care. [109]
14.4.3 Respiratory secretions
Respiratory congestion — the ‘death rattle’ — is usually evident when residents approaching
death cannot clear upper respiratory tract infections. This occurs in approximately 92% of
people who are dying [407] (Level EO). Although most residents who experience respiratory
congestion are likely to be unconscious, it has been suggested that uncontrolled respiratory
congestion may contribute to dyspnoea and restlessness. [403,405] Furthermore, uncontrolled and
exacerbating respiratory congestion can cause distress to families [240,405] (Level IV; Level III-3).
166 Guidelines for a Palliative Approach in Residential Aged Care