Special medical problems in end-of-life care : Crisis at the end of life - Which therapy is adequate and when is redefining treatment goals appropriate?

Abstract

Crisis at the end of life are exceptional challenges for patients, relatives and therapists. With respect to the individual treatment goals and the patients' autonomy, therapeutic action should be commenced in an adequate manner in order to preserve the patients' quality of life as much as possible. Advance care planning for specific critical scenarios may be helpful in order to treat patients according to their wishes and values even if they are not capable to express themselves. Furthermore, acrisis plan can define the scope of action for therapists in emergency situations. Dyspnea, pain and delirium are symptoms that may often lead to emergency calls. In such cases, pharmacological and other treatment options are available. Options for causal therapy should be checked and performed if adequate. Opioids are used to relieve pain and dyspnea. In astate of delirium, highly potent neuroleptics and atypical antipsychotics are used. For the treatment of anxiety or restlessness benzodiazepines can be prescribed. Sedative medication may reduce stress, for instance in the case of acute catastrophic bleeding. Palliative sedation is an ultima ratio concept for refractory symptoms at the end of life. Clinical practice guidelines (such as the German guideline "Palliative care for patients with incurable cancer") may provide an overview of the evidence base on symptom-guided therapy at the end of life.