Clinical Review

ABC of palliative care: The last 48 hours

BMJ 1997; 315 doi: http://dx.doi.org/10.1136/bmj.315.7122.1600 (Published 13 December 1997) Cite this as: BMJ 1997;315:1600
  1. Jim Adam

    Introduction

    During the final 48 hours of life, patients experience increasing weakness and immobility, loss of interest in food and drink, difficulty swallowing, and drowsiness. With an incurable and progressive illness, this phase can usually be anticipated, but sometimes a deterioration can be sudden and distressing. Control of symptoms and family support take priority, and the nature of the primary illness becomes less important. This is a time when levels of anxiety, stress, and emotion can be high for patients, families, and other carers. It is important that the healthcare team adopts a sensitive yet structured approach.

    Principles

    Principles of managing the last 48 hours

    • Problem solving approach to symptom control

    • Avoid unnecessary interventions

    • Review all drugs and symptoms regularly

    • Maintain effective communication

    • Ensure support for family and carers

    An analytical approach to symptom control continues but usually relies on clinical findings rather than investigation. This approach spans all causes of terminal illness and applies to care at home, hospital, or hospice.

    Drugs are reviewed with regard to need and route of administration. Previously “essential” drugs such as antihypertensives, corticosteroids, antidepressants, and hypoglycaemics are often no longer needed and analgesic, antiemetic, sedative, and anticonvulsant drugs form the new “essential” list to work from. The route of administration depends on the clinical situation and characteristics of the drugs used. Some patients manage to take oral drugs until near to death, but many require an alternative route. Any change in medication relies on information from patient, family, and carers (both lay and professional) and regular medical review to monitor the level of symptom control and side effects.

    This review should include an assessment of how the family and carers are coping; effective communication with all involved should be maintained and lines of communication made clear and open. The knowledge that help is available is often a reassurance and can influence the …

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