Perhaps the biggest problem in the treatment of the terminal syndrome of retained respiratory secretions is an inappropriate extrapolation from nonterminal, bacterial pneumonia by both clinicians and families. Although both processes involve the lungs, they are radically different in their pathophysiologies and treatment; what is very appropriate therapy for one may be very inappropriate for the other. Usually, this terminal syndrome is not an isolated process but merely the tip of an iceberg. As the body begins to shut down, widespread organ dysfunction develops. The accumulation of respiratory secretions in the lungs (with or without bacterial pneumonia) is just one of the most visible and audible signs of systemic breakdown.
It is often important to explain to family members (and other clinicians) how this syndrome differs from nonterminal pneumonia. The latter can be viewed as an accident, or at least a complication of some other illness. The body attempts to fight in nonterminal pneumonia. The immune system aggressively responds, and the body tries to cough out the offending organisms. It is reasonable and appropriate to deal with such an invasion by attacking the invading organism. Hydration by IV may help maintain blood pressure until the battle is won and can aid in sputum production, which is useful in promoting a productive cough. Antibiotics assist the body's immune system to fight invading bacteria. Success means a return to baseline health. In the dying process, it is usually impossible to separate what is happening in the respiratory tree from the larger process of dying. Even if life were to be prolonged for a short time with therapies such as antibiotics (which may be perceived as benefit or burden), the patient will not return to a baseline of reasonable health. The patient is still dying, and life prolongation is usually transient, at best.
In this terminal syndrome it is my impression that IV hydration may result in increased respiratory secretions, although studies have not yet clearly demonstrated this to be true. Patients at this stage generally lack a cough. Increased secretions, if present, can be troubling - especially to family members, who are often bothered by the gurgling sound. Deep suctioning is usually futile, as secretions are present in the alveoli and distal bronchioles, not just in the trachea and bronchi. The suction catheter cannot reach these distal bronchioles, and cough may not be stimulated; little is suctioned out. While deep suctioning is discouraged, gentle suctioning of the oral pharynx may be helpful.
The broader use of antibiotics in palliative care is discussed elsewhere. Here it is worth pointing out explicitly that in this syndrome antibiotics are of limited value to the dying patient. (They may have symbolic or ritual value to the family or to clinicians.) In patients who are actively dying, there is no evidence that antibiotics significantly improve quality or quantity of life. If there is an effect, it is likely that antibiotics prolong life to a small degree. For some, prolongation of life by hours to days (if possible) may be a benefit and enable family members to visit and say goodbye. For others, such life prolongation may be considered a burden. If we took away the term "antibiotic" and asked someone, "Consider that you are actively dying. You will probably die within 24 to 48 hours. I can give you a pill that may prolong your dying by a day or so with no great effect on your quality of life. Do you want me to give you that pill?" Many people would decline such an offer. Having said this, obviously we are not always correct in identifying patients as being imminently terminal. This is particularly true for patients with dementia, strokes, and obstructive pulmonary disease, as discussed earlier. One reasonable strategy for the use of antibiotics in patients for whom the goal of care is explicitly comfort only, is not to use antibiotics initially, but only if the patient rallies and begins to recover in the hope of speeding a return to baseline and thereby enhancing comfort. Such a "trial of antibiotics" may seem counterintuitive and is the inverse of how such trials are usually conceived, but it does make sense relative to the described goal of care.
I have suggested that traditional, or at least common, hospital responses to active dying, such as antibiotics and IV hydration, are of minimal, if any, help. Sadly, in palliative care we are often first put on the defensive by having to justify why we believe certain therapies will not help. However, we must not stop here. In fact, there is a great deal we can do to be of assistance to the actively dying and their loved ones.
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Palliative Care Perspectives
James L. Hallenbeck, M.D.
Copyright © 2003 by Oxford University Press, Inc.
The online version of this book is used with permission of the publisher and author on web sites affiliated with the Inter-Institutional Collaborating Network on End-of-life Care (IICN), sponsored by Growth House, Inc.