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Difficulty: EasyEnd-of-Life and Palliative Care

Match each end-of-life clinical scenario or symptom with its most appropriate first-line pharmacologic intervention.

  • Terminal dyspnea (air hunger) in an opioid-naive patient with end-stage chronic obstructive pulmonary disease.Low-dose oral or parenteral morphine
  • Accumulation of noisy respiratory secretions ('death rattle') in an actively dying, unarousable patient.Sublingual hyoscyamine or parenteral glycopyrrolate
  • Severe neuropathic pain secondary to a malignant tumor compressing a spinal nerve root.Adjuvant therapy with gabapentin or pregabalin
  • Severe terminal delirium characterized by acute agitation and distressing visual hallucinations.Administration of a neuroleptic agent such as haloperidol

Answer

Terminal dyspnea is managed with morphine; noisy respiratory secretions with anticholinergics like hyoscyamine; neuropathic pain with gabapentinoids; and terminal delirium with neuroleptics like haloperidol.
Each specific palliative symptom pairs with a targeted pharmacological class: opioids for air hunger, anticholinergics for pooled secretions, nerve-stabilizing agents for radicular/neuropathic pain, and dopamine antagonists for hyperactive delirium.

Step-by-Step Solution

1
Evaluate the management of terminal dyspnea.
Identify that low-dose morphine is the appropriate choice to decrease air hunger.
Opioids reduce the sensitivity of the medullary respiratory center to hypercapnia.
2
Evaluate the management of noisy respiratory secretions.
Identify that hyoscyamine or glycopyrrolate is the appropriate choice.
Anticholinergics reduce the production of saliva and respiratory secretions that pool in the airway of obtunded patients.
3
Evaluate the management of neuropathic pain.
Identify that gabapentin or pregabalin is the appropriate choice.
Neuropathic pain is often opioid-resistant and requires nerve-stabilizing adjuvants.
4
Evaluate the management of hyperactive terminal delirium.
Identify that haloperidol is the appropriate choice.
Neuroleptics safely manage severe agitation and psychotic symptoms at the end of life.

Key Concept

First-line pharmacologic symptom management in palliative care.
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Topics

End-of-Life and Palliative Care

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