Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 2: Symptom Management at End of Life
Clinical Image
Source: Wikimedia Commons - Morphine - CC BY-SA 3.0
Case Presentation
A 68-year-old woman with end-stage heart failure (EF 15%, NYHA Class IV) is admitted with cardiogenic shock. Despite maximum medical therapy including dobutamine and milrinone, she continues to deteriorate with rising lactate and worsening renal function. She is not a candidate for advanced therapies (LVAD, transplant) due to comorbidities. After a family meeting, she and her family decide to transition to comfort-focused care. The sub-intern works with the palliative care team to develop a symptom management plan. Her primary symptoms are dyspnea (despite BiPAP) and anxiety. For dyspnea, morphine 2 mg IV is given, which provides noticeable relief within 15 minutes; a scheduled order for morphine 2-4 mg IV q2h PRN is placed. A fan is positioned to blow cool air across her face, which also reduces her sensation of breathlessness. For anxiety, lorazepam 0.5 mg IV q4h PRN is ordered. As secretions build (death rattle), glycopyrrolate 0.2 mg IV is given to dry secretions, reducing the distressing sound for family (though reassured that it is not causing her distress). Cardiac monitoring is discontinued, as are routine vital signs. Her family is at bedside and is counseled about expected changes: mottling, Cheyne-Stokes breathing, and decreased responsiveness. She dies peacefully 8 hours after transitioning to comfort measures, surrounded by her family.
Key Learning Points
- Opioids are first-line for dyspnea at end of life; they reduce the sensation of breathlessness even in the absence of pain
- The principle of double effect: actions taken to relieve suffering are ethical even if they have a foreseeable but unintended effect of hastening death, as long as the intent is comfort and doses are proportionate
- Death rattle is distressing to families but not to patients (who are typically unconscious); antisecretory medications (glycopyrrolate, scopolamine) reduce the sound
- Monitoring that does not contribute to comfort (telemetry, routine vitals, labs) should be discontinued when the focus shifts to comfort