Palliative Care at the End of Life

In patients with advanced dementia, eating problems followed by infections were the most common complications. Several scales (NHO, ADEPT, PALIAR) have been proposed to estimate 6-months survival. In these patients, a better quality of life could be achieved with palliative care rather than with continued aggressive medical interventions. There is no evidence enough to suggest that enteral tube feeding is beneficial in these patients so careful hand feeding should be offered to them. There is a lack of randomized trials that had examined the effects of antibiotics both on survival and on symptom relief, so caution regarding the initiation of antimicrobial treatment in these patients is recommended. Pain is difficult to assess so it is frequently underdiagnosed and undertreated. No conclusive data are available to support the use of antidementia drugs in patients at stage 7 on the GDS scale. Palliative sedation is indicated in patients with advanced or terminal dementia that present a refractory suffering or symptoms. Midazolam is the first-line choice in palliative sedation in all prevailing symptoms, except delirium, in which case levomepromazine is the first-line choice. In dying patients, current medication should be assessed and non-essentials drugs should be discontinued. At the end of life, drugs needed to be continued should be switched to the subcutaneous route. If appropriate, a syringe driver may be used for continuous infusion. In dying patients, inappropriate interventions (e.g. intravenous fluids, antibiotics, blood tests, measurement of vital signs...) should be stopped.

Keywords: Alzheimer Disease, Anti-Bacterial Agents, Anti-Infective Agents, Aspiration Pneumonia, Decision Making, Deglutition Disorders, Dementia, Enteral Nutrition, Memantine, Mortality, Pain, Palliative Care, Palliative Sedation, Pressure Ulcer, Rivastigmine, Terminal Care, Vascular Dementia.