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P06: Palliative Care - Secretions
Jennie Helmer
Updated:
Reviewed:
Introduction
Secretions and respiratory congestion produce noisy breathing as the movement of mucus and phlegm disrupts the flow of air in the upper airway. Patients who are dying, or who have reduced levels of consciousness or profound weakness, often suffer from excessive oral secretions from the salivary glands. These secretions predict death for up to 75% of patients, often within 48 hours of onset. Bronchial secretions can be caused by respiratory pathologies such as lung infections, aspiration, or pulmonary edema.
Secretions are a common, and expected, symptom in the dying patient. Although the sound can be distressing to family and practitioners, there is no evidence that the sound alone is associated with respiratory distress.
Essentials
- Establish goals of care in consultation and conversation with the patient, family, and care team
- Although the sound of respiratory congestion can be disturbing to hear, determine if the patient is distressed by observing other indications, such as wincing, and provide reassurance to the family
- If the patient seems distressed from their secretions, start medication early for best effect
- Positioning is the most effective non-pharmacological intervention. Reposition the patient in a side-lying position with the head of the bed elevated.
- Deep suctioning may not relieve congestion however, in the event of copious secretions in the oropharynx, gentle anterior suction may be helpful
Additional Treatment Information
- Oxygen has no known patient benefit for respiratory congestion
- Anticholinergics may be more effective when started early, as these drugs do not dry up secretions that are already present
Referral Information
All palliative and end-of-life patients can be considered for inclusion in the Palliative Clinical Pathway (treat and refer) approach to care. Paramedics must complete required training prior to applying this pathway.
Interventions
Emergency Medical Responder (EMR) & All License Levels Interventions
- Establish goals of care in consultation and conversation with the patient, family, and care team. Inform families that noisy breathing may occur as a normal part of the dying process
- Positioning (side-lying with the head of the bed elevated) is the most effective non-pharmacological intervention
Advanced Care Paramedic (ACP) Interventions
- Consider atropine IM
- Consider glycopyrrolate IM
- ACPs may administer patients' own prescribed medication only if the ACP has completed the appropriate Schedule 2 (4(b)) license endorsement. A mandatory call to EPOS for consult is required prior to the administration of any out-of-scope medications.
Evidence Based Practice
References
- Alberta Health Services. AHS Medical Control Protocols. 2020. [Link]
- Ambulance Victoria. Clinical Practice Guidelines: Ambulance and MICA Paramedics. 2018. [Link]
- BC Centre for Palliative Care. B.C. Inter-Professional Palliative Symptom Management Guidelines. 2017. [Link]
- Nova Scotia Health Authority. Nova Scotia Palliative Care Competency Framework. 2017. [Link]
- Pallium Canada. Learning Essentials Approach to Palliative Care. 2019. [Link]
- Pre-Hospital Emergency Care Council. Palliative Care by PHECC registered practitioners. 2016. [Link]