Key Points for This Section

Pain Pain medicines can be given in several ways. Pain during the final hours of life can usually be controlled. Myoclonic jerking may be a side effect of opioid use. Fatigue Shortness of Breath Feeling short of breath is common during the final days or weeks of life. The use of opioids and other methods can help the patient breathe more easily. Cough Death Rattle Rattle occurs when saliva or other fluids collect in the throat and upper airways. Non-drug treatments for rattle include changing the patient's position and giving less fluid. Death rattle is a sign that death may soon occur. Delirium Delirium is common at the end of life. Delirium may be controlled by finding and treating the cause. Hallucinations that are not related to delirium often occur at the end of life. Fever Hemorrhage Sudden hemorrhage (heavy bleeding) may occur in patients who have certain cancers or disorders. Making the patient comfortable is the main goal of care during hemorrhage at the end of life.

Common symptoms at the end of life include pain, feeling very tired, coughing, shortness of breath, rattle, delirium, and fever. Bleeding may also occur.

Pain

Pain medicines can be given in several ways.

In the last days, a patient may not be able to swallow pain medicine. When patients cannot take medicines by mouth, the pain medicine may be given by placing it under the tongue or into the rectum, by injection or infusion, or by placing a patch on the skin. These methods can be used at home with a doctor's order.

Pain during the final hours of life can usually be controlled.

Opioid analgesics work very well to relieve pain and are commonly used at the end of life. Some patients worry that the use of opioids may cause death to occur sooner, but studies have shown no link between opioid use and early death.

(See the PDQ summary on Pain ¹ for more information about opioids.)

Myoclonic jerking may be a side effect of opioid use.

Myoclonic jerks are sudden muscle twitches or jerks that cannot be controlled by the person having them. A hiccup is one type of myoclonic jerk. Myoclonic jerking often occurs in the arms or legs. Taking very high doses of an opioid for a long time may cause this side effect, but it can have other causes as well. In patients taking opioids, it may begin with jerking movements that happen once in a while and then begin to happen more often. Rarely, there is constant jerking of different muscle groups all over the body.

When opioids are the cause of myoclonic jerking, changing to another opioid may help. Different patients respond to opioids in different ways and certain opioids may be more likely than others to cause myoclonic jerking in some people.

When the patient is very near death, medicine to stop the myoclonic jerking may be given instead of changing the opioid. When myoclonic jerking is severe, drugs may be used to calm the patient down, relieve anxiety, and help the patient sleep.

Fatigue

Fatigue (feeling very tired) can have many causes at the end of life. These include physical and mental changes and side effects of treatments. Drugs that increase brain activity, alertness, attention, and energy may be helpful. (See the PDQ summary on Fatigue ² for more information.)

Shortness of Breath

Feeling short of breath is common during the final days or weeks of life.

Shortness of breath or not being able to catch your breath is often caused by advanced cancer. Other causes include the following:

• Build-up of fluid in the abdomen.
• Loss of muscle strength.
• Hypoxemia (a condition in which there is not enough oxygen in the blood).
• Chronic obstructive pulmonary disease (COPD).
• Pneumonia.
• Infection.

The use of opioids and other methods can help the patient breathe more easily.

Very low doses of an opioid may relieve shortness of breath in patients who are not taking opioids for pain. Higher doses may be needed in patients who are taking opioids for pain or who have severe shortness of breath.

Other methods that may help patients who feel short of breath include the following:

• Treating anxiety caused by shortness of breath.
• Directing a cool fan towards the patient’s face.
• Having the patient sit up.
• Having the patient do breathing and relaxation exercises, if able.
• Using acupuncture or acupressure.
• Giving antibiotics if shortness of breath is caused by an infection.
• Giving extra oxygen if shortness of breath is caused by hypoxemia.

In rare cases, shortness of breath may not be relieved by any of these treatments. Sedation with drugs may be needed, to help the patient feel more comfortable.

Some patients have spasms of the air passages in the lungs along with shortness of breath. Bronchodilators (drugs that open up small airways in the lungs) or steroid drugs (which relieve swelling and inflammation) may relieve these spasms.

Cough

Chronic coughing at the end of life may add to a patient's discomfort. Repeated coughing can cause pain and loss of sleep, increase tiredness, and make shortness of breath worse. At the end of life, the decision may be to treat the symptoms of the cough rather than finding and treating the cause. The following types of drugs may be used to make the patient as comfortable as possible:

• Opioids to stop the coughing.
• Corticosteroids to shrink swollen lymph vessels.
• Antibiotics to treat infection.
• Bronchodilators to decrease wheezing and coughing from chronic obstructive pulmonary disease.
• Diuretics to relieve coughing caused by congestive heart failure.

Also, the doctor may look at drugs the patient is already taking, as some drugs (such as ACE inhibitors for high blood pressure or heart failure) can cause cough.

(See the PDQ summary on Cardiopulmonary Syndromes ³ for more information.)

Death Rattle

Rattle occurs when saliva or other fluids collect in the throat and upper airways.

Rattle occurs when saliva or other fluids build up in the throat and airways in a patient who is too weak to clear the throat. There are two types of rattle. Death rattle is caused by saliva pooling at the back of the throat. The other kind of rattle is caused by fluid in the airways from an infection, a tumor, or excess fluid in body tissues.

Drugs may be given to decrease the amount of saliva in the mouth or to dry the upper airway. Since most patients with rattle are unable to swallow, these drugs are usually given in patches on the skin or by infusion.

Non-drug treatments for rattle include changing the patient's position and giving less fluid.

Raising the head of the bed, propping the patient up with pillows, or turning the patient to either side may help relieve rattle. If the rattle is caused by fluid at the back of the throat, excess fluid may be gently removed from the mouth using a suction tube. If the rattle is caused by fluid in the airways, the fluid is usually not removed by suction. Suctioning causes severe physical and mental stress on the patient.

At the end of life, the body needs less food and fluid. Reducing food and fluids can lessen the excess fluid in the body and greatly relieve rattle.

Death rattle is a sign that death may soon occur.

Death rattle is a sign that death may occur in hours or days. Rattle can be very upsetting for those at the bedside. It does not seem to be painful for the patient.

Delirium

Delirium is common at the end of life.

Delirium is common during the final days of life. Some patients may be confused, nervous, and restless, and have hallucinations (see or hear things not really there). Other patients may be quiet and withdrawn. (See the PDQ summary on Cognitive Disorders and Delirium ⁴ for more information.)

Delirium can be caused by the direct effects of cancer, such as a growing tumor in the brain. Other causes include the following:

• A higher- or lower-than-normal amount of certain chemicals in the blood that keep the heart, kidneys, nerves, and muscles working the way they should.
• Side effects of drugs or drug interactions (changes in the way a drug acts in the body when taken with certain other drugs, herbal medicine, or foods).
• Stopping the use of certain drugs or alcohol.
• Dehydration (the loss of needed water from the body).
• A full bladder or constipation.
• Shortness of breath.

Delirium may be controlled by finding and treating the cause.

Depending on the cause of the delirium, treatment may include the following:

• Giving drugs to fix the level of certain chemicals in the blood.
• Stopping or lowering the dose of the drugs that are causing delirium.
• Stopping drugs that may cause drug interactions but are no longer useful at the end of life, such as drugs to lower cholesterol.
• Treating dehydration by putting fluids into the bloodstream.

For some patients in the last hours of life, the decision may be to treat only the symptoms of delirium and make the patient as comfortable as possible. There are drugs that work very well to relieve these symptoms.

Hallucinations that are not related to delirium often occur at the end of life.

It is common for dying patients to have hallucinations that include loved ones who have already died. It is normal for family members to feel distress when these hallucinations occur. Speaking with clergy, the hospital chaplain, or other religious advisors is often helpful.

Fever

Fever and infections are common at the end-of-life. Because patients often have many medical problems at the end of life, it can be hard to know the cause of a fever and if treatment will help the patient. Patients near the end of life may choose not to treat the cause of the fever but only to receive comfort measures, such as acetaminophen.

Hemorrhage

Sudden hemorrhage (heavy bleeding) may occur in patients who have certain cancers or disorders.

Hemorrhage (a lot of bleeding in a short time) is rare but may occur in the last hours or minutes of life. Blood vessels may be damaged by certain cancers or cancer treatments. Radiation therapy, for example, can weaken blood vessels in the area that was treated. Tumors can also damage blood vessels. Patients with the following conditions are at risk for this symptom:

• Head and neck cancers.
• Stomach cancer.
• Esophageal cancer.
• Leukemias and other blood cancers.
• Blood clotting disorders.

The patient should talk with the doctor about any concerns he or she has about the chance of hemorrhage.

Making the patient comfortable is the main goal of care during hemorrhage at the end of life.

When hemorrhage occurs during cancer care, it is treated with bandages and medicines or with treatments such as radiation therapy, surgery, and blood transfusions. When sudden bleeding occurs at the end of life, however, patients usually die soon afterwards. Resuscitation (restarting the heart) usually will not work. The main goal of care is to help the patient be calm and comfortable and to support family members. If hemorrhage occurs, it can be very upsetting for family members. It is helpful if the family talks about the feelings this causes and asks questions about it.

The following steps can be taken when bleeding occurs in the last hours of life:

• Cover the area with dark-colored towels so the blood is not seen.
• Change towels and keep the area clean.
• Speak calmly to the patient and to family members.
• Let the patient know if loved ones are there.

Fast-acting drugs may help calm the patient during this time.

Glossary Terms

The area of the body that contains the pancreas, stomach, intestines, liver, gallbladder, and other organs.

A drug that is used to lower blood pressure. An ACE inhibitor is a type of antihypertensive agent. Also called angiotensin-converting enzyme inhibitor.

A drug that reduces pain and fever (but not inflammation). It belongs to the family of drugs called analgesics.

The application of pressure or localized massage to specific sites on the body to control symptoms such as pain or nausea. It is a type of complementary and alternative medicine.

The technique of inserting thin needles through the skin at specific points on the body to control pain and other symptoms. It is a type of complementary and alternative medicine.

Cancer that has spread to other places in the body and usually cannot be cured or controlled with treatment.

A chemical substance found in beer, wine, and liquor. Alcohol is also found in some medicines, mouthwashes, essential oils (scented liquid taken from plants), and household products.

A drug that reduces pain. Analgesics include aspirin, acetaminophen, and ibuprofen.

A drug used to treat infections caused by bacteria and other microorganisms.

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

The organ that stores urine.

A tissue with red blood cells, white blood cells, platelets, and other substances suspended in fluid called plasma. Blood takes oxygen and nutrients to the tissues, and carries away wastes.

A mass of blood that forms when blood platelets, proteins, and cells stick together. When a blood clot is attached to the wall of a blood vessel, it is called a thrombus. When it moves through the bloodstream and blocks the flow of blood in another part of the body, it is called an embolus.

The administration of blood or blood products into a blood vessel.

A tube through which the blood circulates in the body. Blood vessels include a network of arteries, arterioles, capillaries, venules, and veins.

A type of drug that causes small airways in the lungs to open up. Bronchodilators are inhaled and are used to treat breathing disorders, such as asthma or emphysema.

A term for diseases in which abnormal cells divide without control and can invade nearby tissues. Cancer cells can also spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

A member of the clergy in charge of a chapel or who works with the military or with an institution, such as a hospital.

A waxy, fat-like substance made in the liver, and found in the blood and in all cells of the body. Cholesterol is important for good health and is needed for making cell walls, tissues, hormones, vitamin D, and bile acid. Cholesterol also comes from eating foods taken from animals such as egg yolks, meat, and whole-milk dairy products. Too much cholesterol in the blood may build up in blood vessel walls, block blood flow to tissues and organs, and increase the risk of developing heart disease and stroke.

A disease or condition that persists or progresses over a long period of time.

A type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe. Chronic obstructive pulmonary disease includes chronic bronchitis, in which the bronchi (large air passages) are inflamed and scarred, and emphysema, in which the alveoli (tiny air sacs) are damaged. It develops over many years and is usually caused by cigarette smoking. Also called COPD.

Ordained individuals who perform spiritual and/or religious functions.

A type of research study that tests how well new medical approaches work in people. These studies test new methods of screening, prevention, diagnosis, or treatment of a disease. Also called clinical trial.

A mental state in which one is not thinking clearly.

Weakness of the heart muscle that leads to a buildup of fluid in body tissues.

A condition in which stool becomes hard, dry, and difficult to pass, and bowel movements don’t happen very often. Other symptoms may include painful bowel movements, and feeling bloated, uncomfortable, and sluggish.

Any steroid hormone made in the adrenal cortex (the outer part of the adrenal gland). They are also made in the laboratory. Corticosteroids have many different effects in the body, and are used to treat many different conditions. They may be used as hormone replacement, to suppress the immune system, and to treat some side effects of cancer and its treatment. Corticosteroids are also used to treat certain lymphomas and lymphoid leukemias.

A gurgling sound that comes from the back of the throat of a dying person. It is caused by the build-up of saliva and mucus in the throat and upper airways when the person is too weak to cough.

A condition caused by the loss of too much water from the body. Severe diarrhea or vomiting can cause dehydration.

A mental state in which a person is confused, disoriented, and not able to think or remember clearly. The person may also be agitated and have hallucinations, and extreme excitement.

In medicine, a disturbance of normal functioning of the mind or body. Disorders may be caused by genetic factors, disease, or trauma.

Extreme mental or physical pain or suffering.

A drug that increases the production of urine.

The amount of medicine taken, or radiation given, at one time.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

A change in the way a drug acts in the body when taken with certain other drugs, herbals, or foods, or when taken with certain medical conditions. Drug interactions may cause the drug to be more or less effective, or cause effects on the body that are not expected.

Cancer that forms in tissues lining the esophagus (the muscular tube through which food passes from the throat to the stomach). Two types of esophageal cancer are squamous cell carcinoma (cancer that begins in flat cells lining the esophagus) and adenocarcinoma (cancer that begins in cells that make and release mucus and other fluids).

A condition marked by extreme tiredness and inability to function due lack of energy. Fatigue may be acute or chronic.

An increase in body temperature above normal (98.6 degrees F), usually caused by disease.

Liquid.

A sight, sound, smell, taste, or touch that a person believes to be real but is not real. Hallucinations can be caused by nervous system disease, certain drugs, or mental disorders.

Cancer that arises in the head or neck region (in the nasal cavity, sinuses, lips, mouth, salivary glands, throat, or larynx [voice box]).

In medicine, loss of blood from damaged blood vessels. A hemorrhage may be internal or external, and usually involves a lot of bleeding in a short time.

A type of medicine that uses roots, stems, leaves, flowers, or seeds of plants to improve health, prevent disease, and treat illness.

A blood pressure of 140/90 or higher. High blood pressure usually has no symptoms. It can harm the arteries and cause an increase in the risk of stroke, heart attack, kidney failure, and blindness. Also called hypertension.

Invasion and multiplication of germs in the body. Infections can occur in any part of the body and can spread throughout the body. The germs may be bacteria, viruses, yeast, or fungi. They can cause a fever and other problems, depending on where the infection occurs. When the body’s natural defense system is strong, it can often fight the germs and prevent infection. Some cancer treatments can weaken the natural defense system.

Redness, swelling, pain, and/or a feeling of heat in an area of the body. This is a protective reaction to injury, disease, or irritation of the tissues.

A method of putting fluids, including drugs, into the bloodstream. Also called intravenous infusion.

Use of a syringe and needle to push fluids or drugs into the body; often called a "shot."

One of a pair of organs in the abdomen. Kidneys remove waste from the blood (as urine), produce erythropoietin (a substance that stimulates red blood cell production), and play a role in blood pressure regulation.

Cancer that starts in blood-forming tissue such as the bone marrow and causes large numbers of blood cells to be produced and enter the bloodstream.

One of a pair of organs in the chest that supplies the body with oxygen, and removes carbon dioxide from the body.

A thin tube that carries lymph (lymphatic fluid) and white blood cells through the lymphatic system. Also called lymphatic vessel.

Refers to the practices and procedures used for the prevention, treatment, or relief of symptoms of a diseases or abnormal conditions. This term may also refer to a legal drug used for the same purpose.

A bundle of fibers that receives and sends messages between the body and the brain. The messages are sent by chemical and electrical changes in the cells that make up the nerves.

A drug used to treat moderate to severe pain. Opioids are similar to opiates such as morphine and codeine, but they do not contain and are not made from opium.

A colorless, odorless gas. It is needed for animal and plant life. Oxygen that is breathed in enters the blood from the lungs and travels to the tissues.

PDQ is an online database developed and maintained by the National Cancer Institute. Designed to make the most current, credible, and accurate cancer information available to health professionals and the public, PDQ contains peer-reviewed summaries on cancer treatment, screening, prevention, genetics, complementary and alternative medicine, and supportive care; a registry of cancer clinical trials from around the world; and directories of physicians, professionals who provide genetics services, and organizations that provide cancer care. Most of this information, and more specific information about PDQ, can be found on the NCI's Web site at http://www.cancer.gov/cancertopics/pdq. Also called Physician Data Query.

A severe inflammation of the lungs in which the alveoli (tiny air sacs) are filled with fluid. This may cause a decrease in the amount of oxygen that blood can absorb from air breathed into the lung. Pneumonia is usually caused by infection but may also be caused by radiation therapy, allergy, or irritation of lung tissue by inhaled substances. It may involve part or all of the lungs.

The use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors. Radiation may come from a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy). Systemic radiation therapy uses a radioactive substance, such as a radiolabeled monoclonal antibody, that travels in the blood to tissues throughout the body. Also called irradiation and radiotherapy.

The last several inches of the large intestine closest to the anus.

A method used to reduce tension and anxiety, and control pain.

The watery fluid in the mouth made by the salivary glands. Saliva moistens food to help digestion and it helps protect the mouth against infections.

A drug or substance used to calm a person down, relieve anxiety, or help a person sleep.

A problem that occurs when treatment affects healthy tissues or organs. Some common side effects of cancer treatment are fatigue, pain, nausea, vomiting, decreased blood cell counts, hair loss, and mouth sores.

A bandage-like patch that releases medicine into the body through the skin. The medicine enters the blood slowly and steadily.

A sudden contraction of a muscle or group of muscles, such as a cramp.

A type of drug used to relieve swelling and inflammation. Some steroid drugs may also have antitumor effects.

Cancer that forms in tissues lining the stomach. Also called gastric cancer.

A procedure to remove or repair a part of the body or to find out whether disease is present. An operation.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

The hollow tube inside the neck that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes to the stomach). The throat is about 5 inches long, depending on body size. Also called pharynx.

A group or layer of cells that work together to perform a specific function.

An abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Tumors may be benign (not cancerous), or malignant (cancerous). Also called neoplasm.