: The accuracy of probabilistic versus temporal clinician prediction of survival for patients with advanced cancer: a preliminary report. What other resourcese.g., palliative care, a chaplain, or a clinical ethicistwould help the patient or family with decisions about LST? In another study of patients with advanced cancer admitted to acute palliative care units, the prevalence of cough ranged from 10% to 30% in the last week of life. Hyperextension of the neck: Overextension of the neck: Absent: Present: Inability to close the eyes: Unable to close the eyes: Absent: Present: Drooping of the : Symptom clusters in patients with advanced cancer: a systematic review of observational studies. Total number of admissions to the pediatric ICU (OR, 1.98). 15. Evaluate distal extremities, especially the toes (theend of the oxygen railway) for insight into perfusion and volume status. [12,13] This uncertainty may lead to questions about when systemic treatment should be stopped and when supportive care only and/or hospice care should begin. : Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. This section describes the latest changes made to this summary as of the date above. [3][Level of evidence: II] The proportion of patients able to communicate decreased from 80% to 39% over the last 7 days of life. [54-56] The anticonvulsant gabapentin has been reported to be effective in relieving opioid-induced myoclonus,[57] although other reports implicate gabapentin as a cause of myoclonus. : Symptomatic treatment of infections in patients with advanced cancer receiving hospice care. [36] This compares to a prevalence of lack of energy (68%), pain (63%), and dyspnea (60%). White PH, Kuhlenschmidt HL, Vancura BG, et al. For more information, see Planning the Transition to End-of-Life Care in Advanced Cancer. Wong SL, Leong SM, Chan CM, et al. There are no randomized or controlled prospective trials of the indications, safety, or efficacy of transfused products. AMA Arch Neurol Psychiatry. In one study, as patients approached death, the use of intermittent subcutaneous injections and IV or subcutaneous infusions increased. Campbell ML, Bizek KS, Thill M: Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study. 9. One study has concluded that artificial nutritionspecifically, parenteral nutritionneither influenced the outcome nor improved the quality of life in terminally ill patients.[29]. A prospective observational study that examined vital signs in the last 7 days of life reported that blood pressure and oxygen saturation decreased as death approached. For a patient who was in the transitional state, the probability of dying within a month was 24.1%, which was less than that for a patient in the EOL state (73.5%). Instead of tube-feeding or ordering nothing by mouth, providing a small amount of food for enjoyment may be reasonable if a patient expresses a desire to eat. The first and most important consideration is for health care providers to maintain awareness of their personal reactions to requests or statements. : Goals of care and end-of-life decision making for hospitalized patients at a canadian tertiary care cancer center. What considerationsother than the potential benefits and harms of LSTare relevant to the patient or surrogate decision maker? Considerations of financial cost, burden to patient and family of additional hospitalizations and medical procedures, and all potential complications must be weighed against any potential benefit derived from artificial nutrition support. Predictive factors for whether any given patient will have a significant response to these newer agents are often unclear, making prognostication challenging. Background: Endotracheal tube (ETT) with a tapered-shaped cuff had an improved sealing effect when compared to ETTs with a conventional cylindrical-shaped cuff. 15 These signs were pulselessness of radial artery, respiration with mandibular movement, urine output < 100 ml/12 hours, In several surveys of high-dose opioid use in hospice and palliative care settings, no relationship between opioid dose and survival was found.[30-33]. Variation in the timing of symptom assessment and whether the assessments were repeated over time. [34] Both IV and subcutaneous routes are effective in delivering opioids and other agents in the inpatient or home setting. Finally, the death rattle is particularly distressing to family members. Given the limited efficacy of pharmacological interventions for death rattle, clinicians should consider factors that can help prevent it. Distinctions between simple interventions (e.g., intravenous [IV] hydration) and more complicated interventions (e.g., mechanical ventilation) do not determine supporting the patients decision to forgo a treatment.[. Palliative sedation was used in 15% of admissions. Harris DG, Finlay IG, Flowers S, et al. [4] It is acceptable for oncology clinicians to share the basis for their recommendations, including concerns such as clinician-perceived futility.[6,7]. Step by step examination:Encourage family to stay at bedside during the PE so you can explain findings in lay-person language during the process, to foster engagement and education. J Pain Symptom Manage 43 (6): 1001-12, 2012. Nutrition 15 (9): 665-7, 1999. Whiplash is a common hyperflexion and hyperextension cervical injury caused when the : International palliative care experts' view on phenomena indicating the last hours and days of life. [34] Patients willing to forgo chemotherapy did not have different levels of perceived needs. Addington-Hall JM, O'Callaghan AC: A comparison of the quality of care provided to cancer patients in the UK in the last three months of life in in-patient hospices compared with hospitals, from the perspective of bereaved relatives: results from a survey using the VOICES questionnaire. Hui D, Kilgore K, Nguyen L, et al. J Clin Oncol 30 (20): 2538-44, 2012. Despite their limited ability to interact, patients may be aware of the presence of others; thus, loved ones can be encouraged to speak to the patient as if he or she can hear them. J Palliat Med 2010;13(7): 797. In a survey of the attitudes and experiences of more than 1,000 U.S. physicians toward intentional sedation to unconsciousness until death revealed that 68% of respondents opposed palliative sedation for existential distress. Oncologist 24 (6): e397-e399, 2019. J Pain Symptom Manage 45 (1): 14-22, 2013. One potential objection or concern related to palliative sedation for refractory existential or psychological distress is unrecognized but potentially remediable depression. Safety measures include protecting patients from accidents or self-injury while they are restless or agitated. Swindell JS, McGuire AL, Halpern SD: Beneficent persuasion: techniques and ethical guidelines to improve patients' decisions. Lancet 383 (9930): 1721-30, 2014. A 2018 retrospective cohort study of 13,827 patients with NSCLC drew data from the Surveillance, Epidemiology, and End Results (SEER)Medicare database to examine the association between depression and hospice utilization. [6], Paralytic agents have no analgesic or sedative effects, and they can mask patient discomfort. Am J Hosp Palliat Care 37 (3): 179-184, 2020. 2009. Such a movement may potentially make that joint unstable and increase the risk and likelihood of dislocation or other potential joint injuries. Can the cardiac monitor be discontinued or placed on silent/remote monitoring mode so that, even if family insists it be there, they are not tormented watching for the last heartbeat? Candy B, Jackson KC, Jones L, et al. : Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers. A randomized trial compared noninvasive ventilation (with tight-fitting masks and positive pressure) with supplemental oxygen in a group of advanced-cancer patients in respiratory failure who had chosen to forgo all life support and were receiving palliative care. This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is J Clin Oncol 32 (28): 3184-9, 2014. In addition, a small, double-blind, randomized trial at the University of Texas MD Anderson Cancer Center compared the relative sedating effects of scheduled haloperidol, chlorpromazine, and a combination of the two for advanced-cancer patients with agitated delirium. Cancer 115 (9): 2004-12, 2009. Cranial Nerve Injuries Among the 12 cranial nerves, the facial nerve is most prone to trauma during a vaginal delivery. Lack of training in advance care planning and communication can leave oncologists vulnerable to burnout, depression, and professional dissatisfaction. Psychosomatics 43 (3): 183-94, 2002 May-Jun. 7. A qualitative study of 54 physicians who had administered palliative sedation indicated that physicians who were more concerned with ensuring that suffering was relieved were more likely to administer palliative sedation to unconsciousness. Palliat Med 2015; 29(5):436-442. : Modeling the longitudinal transitions of performance status in cancer outpatients: time to discuss palliative care. Published in 2013, a prospective observational study of 64 patients who died of cancer serially assessed symptoms, symptom intensity, and whether symptoms were unbearable. J Clin Oncol 19 (9): 2542-54, 2001. When applied to palliative sedation, this principle supports the idea that the intended effect of palliative sedation (i.e., relief of suffering) may justify a foreseeable-but-unintended consequence (such as possibly shortening life expectancyalthough this is not supported by data, as mentioned aboveor eliminating the opportunity to interact with loved ones) if the intended (positive) outcome is of greater value than the unintended (negative) outcome. Encouraging family members who desire to do something to participate in the care of the patient (e.g., moistening the mouth) may be helpful. The neck pain from a carotid artery tear often spreads along the side of the neck and up toward the outer corner of the eye. : Hospices' enrollment policies may contribute to underuse of hospice care in the United States. Chicago, Ill: American Academy of Hospice and Palliative Medicine, 2013. J Palliat Med. It is caused by damage from the stroke. Malia C, Bennett MI: What influences patients' decisions on artificial hydration at the end of life? : Occurrence, causes, and outcome of delirium in patients with advanced cancer: a prospective study. PDQ is a registered trademark. Two methods of withdrawal have been described: immediate extubation and terminal weaning.[3]. In one study, however, physician characteristics were more important than patient characteristics in determining hospice enrollment. In contrast, patients with postdiagnosis depression (diagnosed >30 days after NSCLC diagnosis) were less likely to enroll in hospice (SHR, 0.80) than were NSCLC patients without depression. Subscribe for unlimited access. Fast facts #003: Syndrome of imminent death. Decreased response to verbal stimuli (positive LR, 8.3; 95% CI, 7.79). If left unattended, loss, grief, and bereavement can become complicated, leading to prolonged and significant distress for either family members or clinicians. [14] Regardless of such support, patients may report substantial spiritual distress at the EOL, ranging from as few as 10% or 15% of patients to as many as 60%. [, Patients report that receiving chemotherapy facilitates living in the present, perhaps by shifting their attention away from their approaching death. Swan neck deformity is a musculoskeletal manifestation of rheumatoid arthritis presenting in a digit of the hand, due to the combination of:. [45] Another randomized study revealed no difference between atropine and placebo. Providing artificial nutrition to patients at the EOL is a medical intervention and requires establishing enteral or parenteral access. Less common but equally troubling symptoms that may occur in the final hours include death rattle and hemorrhage. : Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. J Pain Symptom Manage 48 (3): 411-50, 2014. Activation of the central cough center mechanism causes a deep inspiration, followed by expiration against a closed glottis; then the glottis opens, allowing expulsion of the air. WebThe upper cervical spine goes into hyperextension with the lordosis curve becoming more pronounced. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Lloyd-Williams M, Payne S: Can multidisciplinary guidelines improve the palliation of symptoms in the terminal phase of dementia? : Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center. Yet, only about half of the studied patients displayed any of these 5 signs (low sensitivity). Cherny N, Ripamonti C, Pereira J, et al. The summary reflects an independent review of In addition to continuing a careful and thoughtful approach to any symptoms a patient is experiencing, preparing family and friends for a patients death is critical. : Bedside clinical signs associated with impending death in patients with advanced cancer: preliminary findings of a prospective, longitudinal cohort study. This type of stroke is rare, we dont know exactly what causes it, but we think its either the hyperextension of the neck, whiplash-type movement during the Campbell ML, Templin T.Intensity cut-points for the respiratory distress observation scale. 12 Signs That Someone Is Near the End of Their Life - Verywell : Drug therapy for delirium in terminally ill adult patients. In one secondary analysis of an observational study of patients who were dying of abdominal malignancies, audible death rattle was correlated with the volume of IV hydration administered. [18] Other prudent advice includes the following: Family members are likely to experience grief at the death of their loved one. This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). Fast Facts and Concepts are edited by Sean Marks MD (Medical College of Wisconsin) and associate editor Drew A Rosielle MD (University of Minnesota Medical School), with the generous support of a volunteer peer-review editorial board, and are made available online by the Palliative Care Network of Wisconsin (PCNOW); the authors of each individual Fast Fact are solely responsible for that Fast Facts content. Truog RD, Cist AF, Brackett SE, et al. 3. Ultimately, the decision to initiate, continue, or forgo chemotherapy should be made collaboratively and is ideally consistent with the expected risks and benefits of treatment within the context of the patient's goals of care. : Early palliative care for patients with metastatic non-small-cell lung cancer. [12] The dose is usually repeated every 4 to 6 hours but in severe cases can be administered every hour. Bioethics 19 (4): 379-92, 2005. Wilson KG, Scott JF, Graham ID, et al. Hui D, Con A, Christie G, et al. Medications, particularly opioids, are another potential etiology. N Engl J Med 342 (7): 508-11, 2000. During the study, 57 percent of the patients died. The use of digital rectal examinations in palliative care inpatients. Phelps AC, Lauderdale KE, Alcorn S, et al. One group of investigators analyzed a cohort of 5,837 hospice patients with terminal cancer for whom the patients preference for dying at home was determined. Functional dysphagia and structural dysphagia occur in a large proportion of cancer patients in the last days of life. Gynecol Oncol 86 (2): 200-11, 2002. J Pain Symptom Manage 42 (2): 192-201, 2011. 8. [21] Fatigue at the EOL is multidimensional, and its underlying pathophysiology is poorly understood. If these issues are unresolved at the time of EOL events, undesired support and resuscitation may result. Coyle N, Adelhardt J, Foley KM, et al. [1-4] These numbers may be even higher in certain demographic populations. The advantage of withdrawal of the neuromuscular blocker is the resultant ability of the health care provider to better assess the patients comfort level and to allow possible interaction between the patient and loved ones. Patients often express a sense that it would be premature to enroll in hospice, that enrolling in hospice means giving up, or that enrolling in hospice would disrupt their relationship with their oncologist. Positional change and neck movement typically displace an ETT and change the intracuff pressure. [3] Other terms used to describe professional suffering are moral distress, emotional exhaustion, and depersonalization. Trombley-Brennan Terminal Tissue Injury Update. Meier DE, Back AL, Morrison RS: The inner life of physicians and care of the seriously ill. JAMA 286 (23): 3007-14, 2001. The recognition of impending death is also an opportunity to encourage family members to notify individuals close to the patient who may want an opportunity to say goodbye. In the final hours of life, care should be directed toward the patient and the patients loved ones. Studies suggest that this aggressive care is associated with worse patient quality of life and worse adjustment to bereavement for loved ones.[42,43]. : Predicting survival in patients with advanced cancer in the last weeks of life: How accurate are prognostic models compared to clinicians' estimates? [3] The following paragraphs summarize information relevant to the first two questions. This extreme arched pose is an extrapyramidal effect and is caused by spasm of A necessary goal of high-quality end-of-life (EOL) care is the alleviation of distressing symptoms that can lead to suffering. Hamric AB, Blackhall LJ: Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. What is the intended level of consciousness? Additionally, families can be educated about good mouth care and provision of sips of water to alleviate thirst. 2023 Palliative Care Network of Wisconsin, About Palliative Care Network of Wisconsin, CAR-T Cell Immunotherapy: What You Need To Know . [, Patients and physicians may mutually avoid discussions of options other than chemotherapy because it feels contradictory to the focus on providing treatment.[. Fast Facts can only be copied and distributed for non-commercial, educational purposes. The preferred citation for this PDQ summary is: PDQ Supportive and Palliative Care Editorial Board. Moderate or severe pain (43% vs. 69%; OR, 0.56). : Character of terminal illness in the advanced cancer patient: pain and other symptoms during the last four weeks of life. Keating NL, Beth Landrum M, Arora NK, et al. Psychosomatics 43 (3): 175-82, 2002 May-Jun. J Pain Symptom Manage 48 (5): 839-51, 2014. The distinction between doing and allowing in medical ethics. : The quality of dying and death in cancer and its relationship to palliative care and place of death. 2015;128(12):1270-1. Terminal weaning.Terminal weaning entails a more gradual process. Wright AA, Hatfield LA, Earle CC, et al. Reciprocal flexion of the metacarpal phalangeal joint (MCP) can also be present. For more information, see Spirituality in Cancer Care. Monitors and alarms are turned off, and life-prolonging interventions such as antibiotics and transfusions need to be discontinued. : The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study. An important strategy to achieve that goal is to avoid or reduce medical interventions of limited effectiveness and high burden to the patients. [11][Level of evidence: III] As the authors noted, these findings raise concerns that patients receiving targeted therapy may have poorer prognostic awareness and therefore fewer opportunities to prepare for the EOL. National Coalition for Hospice and Palliative Care, 2018. At this threshold, the patient received lorazepam 3 mg or matching placebo with one additional dose of haloperidol 2 mg. A database survey of patient characteristics and effect on life expectancy. J Pain Symptom Manage 46 (3): 326-34, 2013. Morita T, Ichiki T, Tsunoda J, et al. Pellegrino ED: Decisions to withdraw life-sustaining treatment: a moral algorithm. : Factors contributing to evaluation of a good death from the bereaved family member's perspective. This type of fainting can occur when someone wears a very tight collar, stretches or turns the neck too much, or has a bone in the neck that is pinching the artery. J Pain Symptom Manage 57 (2): 233-240, 2019. The motion of the muscles of the neck are divided into four categories: rotation, lateral flexion, flexion, and hyperextension. Specifically, patients often experience difficulty swallowing both liquids and solids, which is often associated with anorexia and cachexia. Support Care Cancer 17 (1): 53-9, 2009. 6. [3] However, simple investigations such as reviewing medications or eliciting a history of symptoms compatible with gastroesophageal reflux disease are warranted because some drugs (e.g., angiotensin-converting enzyme inhibitors) cause cough, or a prescription for antacids may provide relief. The aim of the current study was to compare the ETT cuff pressure in the : Contending with advanced illness: patient and caregiver perspectives. WebFever may or may not occur, but is common nearer to death. [22] Families may be helped with this decision when clinicians explain that use of artificial hydration in patients with cancer at the EOL has not been shown to help patients live longer or improve quality of life. Documented symptoms, including pain, dyspnea, fever, lethargy, and altered mental state, did not differ in the group that received antibiotics, compared with the patients who did not. Clark K, Currow DC, Agar M, et al. How do the potential benefits of LST contribute to achieving the goals of care, and how likely is the desired outcome? Centeno C, Sanz A, Bruera E: Delirium in advanced cancer patients. Because of the association of longer hospice stays with caregivers perceptions of improved quality of care and increased satisfaction with care, the latter finding is especially concerning. Such patients may have notions of the importance of transfusions related to how they feel and their life expectancies. Edema severity can guide the use of diuretics and artificial hydration. Clark K, Currow DC, Talley NJ. In addition, 29% of patients were admitted to an intensive care unit in the last month of life. The early signs had high frequency, occurred more than 1 week before death, and had moderate predictive value that a patient would die in 3 days. Boland E, Johnson M, Boland J: Artificial hydration in the terminally ill patient. Clin Nutr 24 (6): 961-70, 2005. J Palliat Med 13 (5): 535-40, 2010. A meconium-like stool odor has been associated with imminent death in dementia populations (19). Med Care 26 (2): 177-82, 1988. [12,14,15], Patients with advanced cancer who receive hospice care appear to experience better psychological adjustment, fewer burdensome symptoms, increased satisfaction, improved communication, and better deaths without hastening death. Relaxed-Fit Super-High-Rise Cargo Short 4". Ann Fam Med 8 (3): 260-4, 2010 May-Jun. J Pain Symptom Manage 47 (1): 77-89, 2014. Survival time was overestimated in 85% of patients for whom medical providers gave inaccurate predictions, and providers were particularly likely to overestimate survival for Black and Latino patients.[4]. Unsurprisingly, mental status remained the same or worsened for all patients who received continuous palliative sedation for delirium. Bedside clinical signs associated with impending death in In considering a patients request for palliative sedation, clinicians need to identify any personal biases that may adversely affect their ability to respond effectively to such requests. Mental status changes in the 37 patients who received intermittent palliative sedation for delirium were as follows, after sedation was lightened: 43.2% unchanged, 40.6% improved, and 16.2% worsened. : Clinical Patterns of Continuous and Intermittent Palliative Sedation in Patients With Terminal Cancer: A Descriptive, Observational Study. Only 8% restricted enrollment of patients receiving tube feedings. Immediate extubation includes providing parenteral opioids for analgesia and sedating agents such as midazolam, suctioning to remove excess secretions, setting the ventilator to no assist and turning off all alarms, and deflating the cuff and removing the endotracheal tube. JAMA 297 (3): 295-304, 2007. Smith LB, Cooling L, Davenport R: How do I allocate blood products at the end of life? : Symptom prevalence in the last week of life. A Q-methodology study. Large and asymmetrically nonreactive pupils may be a dire warning for imminent death from brain herniation. Cardiovascular:Unless peripheral pulses are impalpable and one seeks rate and rhythm, listening to the heart may not always be warranted. Patients may also experience gastrointestinal bleeding from ulcers, progressive tumor growth, or chemotherapy-induced mucositis. However, two qualitative interview studies of clinicians whose patients experienced catastrophic bleeding at the EOL suggest that it is often impossible to anticipate bleeding and that a proactive approach may cause patients and families undue distress. Arch Intern Med 160 (6): 786-94, 2000. Bennett M, Lucas V, Brennan M, et al. Mak YY, Elwyn G: Voices of the terminally ill: uncovering the meaning of desire for euthanasia. Moderate changes in vital signs from baseline could not definitively rule in or rule out impending death in 3 days. Oncologists and nurses caring for terminally ill cancer patients are at risk of suffering personally, owing to the clinical intensity and chronic loss inherent in their work. Hui D, dos Santos R, Chisholm GB, et al. [41], A retrospective analysis of 321 pediatric cancer patients who died while enrolled on the palliative care service at St. Jude Childrens Research Hospital suggests that the following factors (with ORs) were associated with a higher likelihood of dying in the pediatric ICU:[42], Pediatric care providers may want to consider the factors listed above to identify patients at higher risk of dying in an intensive inpatient setting, and to initiate early conversations about goals of care and preferred place of death.[42]. : Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Along with patient wishes and concomitant symptoms, clinicians should consider limiting IV hydration in the final days before death. JAMA 284 (19): 2476-82, 2000. Symptoms often cluster, and the presence of a symptom should prompt consideration of other symptoms to avoid inadvertently worsening other symptoms in the cluster. J Pain Symptom Manage 12 (4): 229-33, 1996. There is no evidence that palliative sedation shortens life expectancy when applied in the last days of life.[. Shimizu Y, Miyashita M, Morita T, et al. The cough reflex protects the lungs from noxious materials and clears excess secretions. That such information is placed in patient records, with follow-up at all appropriate times, including hospitalization at the EOL. Anderson SL, Shreve ST: Continuous subcutaneous infusion of opiates at end-of-life. The PPS is an 11-point scale describing a patients level of ambulation, level of activity, evidence of disease, ability to perform self-care, nutritional intake, and level of consciousness. [2,3] This appears to hold true even for providers who are experienced in treating patients who are terminally ill. Enrollment in hospice increases the likelihood of dying at home, but careful attention needs to be paid to caregiver support and symptom control. Musculoskeletal:Change position or replace a pillow if the neck appears cramped. Ford DW, Nietert PJ, Zapka J, et al. Sutradhar R, Seow H, Earle C, et al. WebJoint hypermobility predisposes individuals in some sports to injury more than other sports. : Management of chronic cough in patients receiving palliative care: review of evidence and recommendations by a task group of the Association for Palliative Medicine of Great Britain and Ireland. Am J Hosp Palliat Care 19 (1): 49-56, 2002 Jan-Feb. Kss RM, Ellershaw J: Respiratory tract secretions in the dying patient: a retrospective study. A final note of caution is warranted. [22] This may reflect the observation that patients concede more control to oncologists over time, especially if treatment decisions involve noncurative chemotherapy for metastatic cancer.[23]. Many patients fear uncontrolled pain during the final days of life, but experience suggests that most patients can obtain pain relief and that very high doses of opioids are rarely indicated. EPERC Fast Facts and Concepts;J Pall Med [Internet]. X50.0 describes the circumstance causing an injury, not the nature of the injury. 2015;12(4):379. History of hematopoietic stem cell transplant (OR, 4.52). Recognizing that the primary intention of nutrition is to benefit the patient, AAHPM concludes that withholding artificial nutrition near the EOL may be appropriate medical care if the risks outweigh the possible benefit to the patient. In intractable cases of delirium, palliative sedation may be warranted. White patients were more likely to receive antimicrobials than patients of other racial and ethnic backgrounds. Ruijs CD, Kerkhof AJ, van der Wal G, et al. While the main objective in the decision to use antimicrobials is to treat clinically suspected infections in patients who are receiving palliative or hospice care,[62-64][Level of evidence: II] subsequent information suggests that the risks of using empiric antibiotics do not appear justified by the possible benefits for people near death.[65]. : Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. : Hydration and nutrition at the end of life: a systematic review of emotional impact, perceptions, and decision-making among patients, family, and health care staff.