Caring for dying patients in the intensive care unit: managing pain, dyspnea, anxiety, delirium, and death rattle.

Abstract

Critically ill patients receiving palliative care at the end of life are at high risk for experiencing pain, dyspnea, and death rattle. Nearly all these patients are at risk for the development of delirium. Patients who are alert may experience anxiety. Advanced practice nurses and staff nurses are integral to detecting and treating these symptoms. Pain, dyspnea, and anxiety should be routinely assessed by patient self-report when possible. Routine behavioral screening for delirium is recommended. Behavioral observation tools to detect pain and dyspnea and proxy assessments guide symptom identification when the patient cannot provide a self-report. Evidence-based interventions are offered for both prevention and treatment of pain, dyspnea, anxiety, and delirium. Death rattle does not produce patient distress, and current pharmacological treatment lacks an evidence base. Pain management has a robust evidence base compared to management of dyspnea, anxiety, and delirium among this population; well-designed, adequately powered studies are needed.