palliative care for a dying planet
|"Get six jolly cowboys to carry my coffin
Get six pretty maidens to bear up my pall
Put bunches of roses all over my coffin
Roses to deaden the clods as they fall
Oh, beat the drums slowly and play the fife lowly
And play the dead march as you carry me along.
Take me to the green valley and lay the sod o'er me.
For I'm a young cowboy, and I know I've done wrong."
||Song: The Streets of Laredo, traditional
For more information:
Some more lyrics in this style ...
Oh please ne'er forget me though waves now lie o'er me
I was once young and pretty and my spirit ran free
But destiny tore me from country and loved ones
And from the new land I was never to see.
An Emigrant's Daughter - audio
An emigrant's daughter - lyrics
Feleena knelt near him, to hold and to hear him,
When she felt the warm blood that flowed from the wound in his side;
He raised to kiss her and she heard him whisper:
"Never forget me - Feleena it's over, goodbye."
Quickly she grabbed for the six-gun that he wore
And screamin' in anger and placin' the gun to her breast:
"Bury us both deep and maybe we'll find peace",
And pullin' the trigger, she fell 'cross the dead cowboy's chest.
Feleena - audio
Feleena - lyrics
So you think you can love me and leave me to die
Oh, baby, can't do this to me, baby
Just gotta get out, just gotta get right outta here
Nothing really matters, Anyone can see
Nothing really matters
Nothing really matters to me
Any way the wind blows
"Bohemian Rhapsody" [Queen]
|Cassandra source: http://www.geocities.com/Athens/Acropolis/6537/fict-c.htm
|Yet one word more, a prophecy--or, if a dirge,
At least not mine alone. In this sun's light--my last--
I pray: when the sword's edge requites my captor's blood,
Then may his murderers, dying, with that debt pay too
For her they killed in chains, their unresisting prey!
Alas for human destiny! Man's happiest hours
Are pictures drawn in shadow. Then ill fortune comes,
And with two strokes the wet sponge wipes the drawing out.
And grief itself's hardly more pitiable than joy.
||Play: Agamemnon by Aeschylus
||For more information:
Kassandra - Krista Wolf
|Enkidu source: http://www.geocities.com/Athens/Acropolis/6537/fict-c.htm
|"My friend, the great goddess cursed me and I must die
in shame. I shall not die like a man fallen in battle: I feared to
fall, but happy is the man who falls in battle, for I must die in shame."
||For more information:
More poetry (new window)
Terminal care for a dying planet
Note 1: We wondered whether the many illusionary suggestions to save the world whilst maintaining our overshoot lifestyles could be compared to palliative care for terminally ill patients. An internet search produced the below guidelines as one of the fits hits. We keep wondering.
Note 2: Many of the below indications must make sense from a medical and social point of view. But we strongly oppose the below recommendations to use phamacological drugs. We find the notice "In resistant cases" far too unspecified and open to interpretation and abuse. People should not be forced to take drugs. "Specialists" should be carefully selected with regard to their professional background and phychopharmacological preferences.
Note 3: The terms "symptom management" and "dignity" are central. Arguably symptom management is the best we can do in order to maintain our human dignity as long as possible, on the downslope of environmental and social collapse.
- The term ‘terminal phase’ or ‘mode’ refers to the hours or days
immediately preceding death.
- Terminal care is active care with a focus on symptom management and dignity.
- The first step in the delivery of appropriate and timely terminal
care is to recognise
- Terminal care is based on an understanding that death is imminent
and unavoidable, and that efforts to prolong life are no longer
- All patient care at this time relates directly to the patient’s
level of comfort.
- Whilst good care can nearly always make a favourable contribution to
comfort and dignity, there are few perfect deaths, just as there are few perfect
births. Death cannot be ‘tamed’ or defeated; it certainly cannot be
- Where possible, the transition to terminal care should be pre-empted and done
gradually so that all concerned can adapt. Planning for anticipated changes and
possible emergencies is necessary. However, rapid changes in condition, or a
reluctance to confront the realities of the situation, may not permit this.
- For family and friends this will be the last memory of the dying
person, and their
experience of this time may have a profound impact on their grief and
- Terminal care is deployed for patients who are assessed as having reached the
terminal phase of their illness. A person may perceive themselves as being close to
the end of their life, and clinicians should be open to such patient-initiated ‘death
talk’, even if it does not quite fit with the clinical data.
- This clinical component of the assessment is sometimes referred to medically as
‘diagnosing’ dying. Diagnosing dying is a process. It does not usually require any new
- The process is not always clear-cut, as a patient’s condition can oscillate, and
prognostication is inherently problematic.
- It is therefore a matter of ‘making a call’, on the basis of objective and subjective
evidence, intuition and experience.
- Good knowledge of the patient from family, carers, nursing staff and others may be
just as reliable as a medical opinion when it comes to survival estimates.
- Sharing the uncertainties of the situation is important: dying is an unstable and
- Despite every effort to get it right, a ‘wrong’ call, where a patient’s prognosis may be
longer than anticipated, and communicated, is rarely a problem if there is good
communication, and such ‘grief work’ is rarely wasted for patients and families.
- The ‘diagnosis’ of dying is usually based on clinical evidence:
Key Prognostic Questions
- disease progression;
- body systems failure; and
- overt and covert patient behaviour, emotional and physical: e.g. withdrawal from
the world, increasing drowsiness, and increasing weakness, more time in bed,
eating and drinking decreasing, difficulty swallowing medications, talking about
death and dying.
- Is this deterioration likely to be due to a reversible condition whose investigation
and treatment would not be excessively burdensome?
- Would it be surprising if the patient were to die within the few hours or days; or if
in hospital, during or shortly after this admission?
(based on the approach of Murray et al )
- Clarify and confirm the patient’s end of life wishes with the patient/family/caregivers.
- Provide the best possible pain and symptom control in the circumstances.
- Anticipate and prepare for eventualities - ‘hope for the best but plan for the worst’.
This may include anticipatory medication orders, crisis orders, etc.
- Appropriate social, spiritual, and emotional accompaniment of the dying patient and
their family and/or friends.
- Provide timely information and support.
- The role of the DHHS Palliative Care Services is to provide consultation, shared
care or direct care depending on patient and family need, wishes and location of
- For inpatients it is strongly suggested that the inpatient end of life care pathway
be activated (see End of Life Care Pathway).
- Observations, investigations, and interventions that are a routine part of life-maintaining care are no longer appropriate.
- Ongoing assessment of signs and symptoms of impending death.
- A syringe driver is a useful tool in medication delivery, but is not an automatic
necessity. It is used to infuse specific drugs for specific symptoms, usually when
using the oral route is no longer possible.
- Morphine and other opioids are indicated for the specific indications of relief of pain
or shortness of breath only.
- Whether an inpatient or at home, good general nursing care is at the core of patient
comfort and dignity at the end of life. Essential elements are:
- regular attention to mouth care and general hygiene;
- use of pressure relieving cushions and mattresses to prevent skin breakdown,
regular, regimented change in position may not be appropriate in the last hours
or days if the patient is comfortable; and
- managing bowel and bladder care to prevent constipation and urinary retention.
Provision of Nutrition and Hydration
- Decrease and eventual cessation of oral intake is a normal part of the dying process.
- The medical provision of hydration and nutrition (via PEG, naso-gastric or IV routes)
is not indicated during the final phases of the dying process.
- Food and drink are always made available to conscious patients if they would like it.
- Very occasionally the provision of subcutaneous fluids (hypodermoclysis) may be
tried for severe symptomatic thirst in conscious patients.
- Oral comfort is maintained by regular mouth care. Families and carers can assist
Principles of Medication Management in Terminal Care
- Review medications with a view to rationalisation: assess which medications need to
be continued for symptomatic relief, and which have the primary function of
preventing long term complications of disease and can be ceased e.g.
antihypertensives, hypoglycaemias, or anticoagulants.
- Ensure the patient and/or family understand the reasoning behind the changes.
- Anticipate the need to change the delivery route of medications as the patient
develops difficulties with swallowing.
- Anticipate parenteral medications that may be needed rapidly or urgently. Ensure
that written orders for these are in place and the medication is available.
- Opioid dose escalation when pain is not an issue is not indicated in dying patients.
Opioids and their metabolites may cause agitation and promote pain, hyperalgesia
- Where renal function is deteriorating, reduce the dose of renally eliminated
medications or find alternatives.
Note: It is never appropriate to simply sedate a patient with severe pain or dyspnoea as
sedation does nothing to relieve the causal symptom(s).
- Families require:
- information about community supports available to them, including GP
availability and 24 hour support;
- information about, and interpretation of, the patients condition to enable them
to understand the dying process;
- instruction in carrying out the daily tasks of caregiving;
- support to help them manage the physical and emotional demands they will
- validation of their contribution to the patient’s comfort;
- recognition of the need for respite, including overnight care;
- clear instructions to follow for:
- possible emergencies;
- identifying when the patient has died; and
- what to do when the patient dies.
- opportunities for follow up to discuss the death and any unresolved questions.
Some degree of agitation, moaning, jerking, or twitching are all common during the dying
process, and this can be very variable. It is sometimes difficult to differentiate between a
potentially reversible or self limiting agitated delirium and the onset of terminal
Consider potentially reversible causes:
- urinary retention and/or constipation;
- physical discomfort: too hot, too cold, uncomfortable position;
- environment: noisy, too bright, too dark;
- emotional or spiritual distress;
- accumulation of renally eliminated drugs e.g. morphine and metabolites;
- cumulative anticholinergic load:
- tricyclic antidepressants; or
- others – digoxin, alprazolam, ranitidine.
- withdrawal: drugs, nicotine.
Management – Non pharmacological
- Physical comfort;
- Quiet unchanging environment; low light to assist with orientation;
- Familiar company;
- Music/music therapy; and
- If the patient is a danger to themselves or others, sedating medication may be
needed (see below).
Management - pharmacological
For conscious patients with disturbance of thought content try:
Where sedation is a desired or necessary outcome (also where muscle relaxation is
- Haloperidol 0.5 - 2.5mg orally, up to 6 hrly.
- Haloperidol 0.5 - 1mg SC three times a day, or 2.5 - 5mg / 24 hours by
continuous subcutaneous infusion (CSCI).
- Midazolam 2.5 - 5 mg sc prn, 15 - 30 mg/24hour by CSCI.
In resistant cases:
- Clonazepam 0.2mg sublingually SL (drops) or S/C prn or 1 - 5mg / 24 hours by
regular SL drops or S/C injection 8 – 12 hrly
Seek specialist advice (Delirium Care Management Guidelines and the Adult Palliative Care
- Phenobarbitone may be tried 200mg sc stat, and 600 - 1200 mg / 24 hr CSCI
- Noisy laboured breathing is common during the dying process. It is usually due to
pooling of secretions in the pharynx and is similar to a snore.
- Pooled oral secretions are due to the loss of swallowing reflex, congestion due to
weak respiratory muscles, and the loss of the cough reflex.
- Secretions are best managed with good mouth care, and by positioning the patient
side to side with the head elevated a little to encourage drainage, maintain the
airway and decrease the pooling of secretions. Pharyngeal suction is usually
contraindicated. Medication is not usually effective once noisy gurgling (‘death
rattle’) is established.
- Explain to the family that:
- the secretions are not usually bothersome to the patient;
- the secretions are not usually accessible to suctioning;
- deep suctioning is a physically distressing procedure;
- medications to dry secretions may dry everything including the mouth and eyes,
and contribute to patient discomfort; and
- back ground music etc. will distract from the noise.
- Try anti-cholinergic:
If the patient is distressed and struggling, sedation will usually be required. Refer to
- Hyoscine hydrobromide 0.4mg 4/24 sc prn or 0.8 - 2.0mg/day CSCI (beware of
potential anticholinergic CNS effects);
- Atropine 0.6 - 1.2 mg 4 - 6/24 sc prn (beware of potential anticholinergic CNS
- Glycopyrronium bromide (Glycopyrrolate) 0.4 - 0.8 mg sc prn or 0.8 - 2.0mg /
Note: not PBS funded; good choice for conscious patients where secretions are an issue.
(see Consultation and Advice below)
- Hyoscine butylbromide 20mg 4/24 sc or 80 - 120mg / 24hrs CSCI
Adult Palliative Care Formulary
Note: Noisy tachypnoea can only be managed by reducing the respiratory rate to
normal through the titration of opioids and sedative medications.
- Physical discomfort should not be accepted as inevitable and part of the dying
process. Weakness and inactivity bring their own discomfort, joints often become
stiff and sore and skin is less resilient with pressure.
- If verbal pain reporting is still possible, be guided by the patient’s reports.
- If the patient is not able to talk to you or is not coherent, observe ‘antalgic’
behaviour, especially on movement: signs of physical discomfort such as grimacing,
frowning, vocalising and stiffening on movement.
- Base management on these observations, and on response to analgesic
- Titrate opioid according to breakthrough requirements. Observe response.
- If no response, then try adding ketorolac or low dose ketamine Pain Management –
Care Management Guidelines.
- Avoid steroids due to central effects – sleep disturbance, agitation and psychiatric
- Some oral drugs such as NSAID’s and paracetamol may have to be stopped or given
by another route.
Consultation and Advice
Seek advice when:
Revision history and planned frequency
- There is unrelieved distress and terminal restlessness. If symptoms are not
responsive to recognised management this should be considered a palliative
emergency and specialist advice sought.
- For conscious patients where secretions are an issue and for access to
- When there is significant family, caregivers or staff distress.
Endorsed September 2009
Next review September 2010